PRE-ADMISSION SCREENING FORM PLEASE NOTE: If you are currently suicidal or experiencing a psychiatric crisis, immediately contact Crisis Services at (330) 725-9195. Name * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### Email Date Of Birth MM DD YYYY Race Gender Male Female Prefer Not To Say Marital Status Military Service Connected Yes No Medical Insurance None Medicaid Medicaid Part B Private Income Source Employed SSI/SSDI Spouse/Parental Support Other Guardian Yes No Guardian Name First Name Last Name Guardian Relationship Guardian Phone (###) ### #### Emergency Contact First Name Last Name Relationship Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### May We Leave A Message At This Number? Yes No May We Mail You At This Address? Yes No Requested Services Psychiatrist Counseling Case Management Groups Referral Source Self Family/Friend Hospital Court/Probation Phone (###) ### #### Reason For Transfer/Request Signs/Symptoms (Check All That Apply) Anxiety/Worry Depression/Sadness Repeated Habits/Rituals Excessive Fearfullness Hear/See Things That Others Don't Intrusive Thoughts Angry Outbursts Suspicious Of Others Mood Swings Change In Eating Pattern Change In Sleep Pattern Victim Of Physical, Sexual Or Emotional Abuse History Of Suicide Attempts History Of Violence Towards Others Additional Info On Items Checked Have You Been Hospitalized For Psychiatric Care? Yes No If Yes, Please List When, Where & Why Your Compliance With Treatment Was Very Consistent Somewhat Consistent Inconsistent Have You Ever Abused, Misused Or Had Concerns With Drug Use? Yes No Have You Ever Abused, Misused Or Had Concerns With Alcohol Use? Yes No Have You Ever Received Drug/Alcohol Treatment (Inpatient or Outpatient)? Yes No If Yes, Please List When And Where Do You Have Any Pending Legal Charges And/Or Are You Currently On Probation Or Parole? Yes No If Yes, Please List Which Court Name Of Probation Officer First Name Last Name Phone Of Probation Officer (###) ### #### Do You Have Any Past Arrests/Incarcerations/Legal Involvement? Yes No If Yes, Please Explain I Care For My Health, Financial, & Household Needs Strongly Agree Agree Neutral Disagree Strongly Disagree My Mental Health Symptoms Prevent Me From Functioning At Home/Work Strongly Agree Agree Neutral Disagree Strongly Agree Thank you!
