Name*

First Name

Last Name

Are you currently incarcerated? *

Yes

No

Have you been incarcerated before? *

Yes

No

When is your parole/review date?

MM

DD

YYYY

When is your release date?

MM

DD

YYYY

Date of last use:

MM

DD

YYYY

Have you ever been hospitalized for mental/emotional problems? *

Yes

No

Are you pregnant? *

Yes

No

If yes, when are you due?

MM

DD

YYYY

Have you received prenatal care?

Yes

No

Have you ever been treated for attempted suicide?

Yes

No

If yes, when?

MM

DD

YYYY

Do you have any physical conditions that require medication? *

Yes

No

SSI/SSD? *

Yes

No

Have you applied for SSI/SSD?

Yes

No

Will you apply for SSI/SSD?

Yes

No

Have you ever lived in Transitional Housing before? *

Yes

No

What type of treatment have you received in the past: (check all that apply):

Individual therapy

Group therapy

Substance abuse treatment

In-home case Management

Intensive outpatient

Inpatient care

Residential care

Partial hospitalization