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Pre-Admission Screening Questionnaire

Fill out the form below or download a printer friendly pdf version of this questionnaire

Name:

Phone number where you can be reached:

Is it OK to call you at this phone number? Yes No

If so, can we leave a message? Yes No

If you don’t want us to contact you, please call the clinical director at 273-9541 to set up an appointment

Address:

Age:

Service Requested:

County:

Funding/Insurance Source:

Monthly Income:

Source of Income:

Gender: Male Female

Ethnicity:

Do you have children? Yes No

How Many?

Ages:

Gender

Current Medications:

Names & Amounts Taken Daily:

Current Supply for How Long:

Current Doctor's Name:

Doctor's Contact Info:

May we contact your doctor about your condition? Yes No

Medical Problems:

Current Psychiatrist Name:

Psychiatrist Diagnosis:

Primary and Secondary Drug of Choice:

Last Use:

Route of Administration:

How long have you used?

Last Date of Physical:

Last Date of TB Test:

Probation/Parole? Yes No

Probation/Parole Officers Name:

Prior Arrests for:

Sexual offense history? Yes No

Are you a registered sex offender? Yes No

Significant Other?

Where Referred?

Prior Treatment?

Violence Offense History? Yes No

Family Support?

Where Referred?

Questions for Mental Health
Have you ever been worried about your thinking, feeling, or acting?
Yes No

Has anyone ever expressed concerns about how you your thinking, feeling, or acting?
Yes No

Have you ever harmed yourself? Or thought about harming yourself?
Yes No

Questions for Alcohol & Drug Use
Have you ever had any problems related to you use of alcohol and or other drugs?
Yes No

Has a relative, friend, doctor, other health worker, ever been concerned about your drinking or other drug use, suggested cutting down?
Yes No

Have you ever said to another person, "No I don't have an alcohol or drug problem," when around the same time you questioned yourself and felt maybe I do have a problem?
Yes No

Questions for Trauma/Domestic Violence
Have you ever been in a relationship where your partner has pushed or slapped you?
Yes No

Before you were 13, was there any time you were punched, kicked, choked, or received a more serious physical punishment from a parent or other adult?
Yes No

Before you were 13, did anyone ever touch you in a sexual way or make you touch them when you did not want to?
Yes No

Is there anything that would have made this questionnaire more welcoming?

Is there anything else you'd like us to know?

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CoRR | Grass Valley 530-273-9541 | South County 530-268-2356 | Truckee 530-587-8194
Hope House Women's Residential Facility | Phone 530-271-1140

Make a lasting difference in the community by remembering CoRR in your will or trust

-EDITS-