Intake Assessment - Clarksburg Mission

INTAKE ASSESSMENT FORM

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Personal Information

Name*

First Last

Birth Date*

Phone Number*

Marital Status*

Gender*

Email*

Emergency Contact*

Phone*

High School*

Graduate*

College*

Degree*

Driver’s License*

State*

Number*

Do you drive?*

Where are you from*

Legal Involvement

Parole/Probation Name*

Phone Number*

Parole/Probation Start Date*

Expected Release*

Charge for Parole/Probation*

Registered Sex Offender*

Yes

No

Drug/Alcohol History

Drug of choice*

Overdosed*

Had Narcan*

Clean Date*

Detox – Treatment – Hospitalization

Do you have a Sponsor*

Facility*

Date*

Facility*

Date*

Facility*

Date*

Facility*

Date*

Health Information

Insurance Type*

If Private, please specify*

Allergies*

Physical Health Diagnosis*

Mental Health Diagnosis*

Income

SSI $*

SSDI $*

Other $*

Vital Records Needed

Birth Certificate*

SSC*

ID*

Employment History

Employer Name*

Start*

End*

Employer Address*

Reason for Leaving*

Supervisor Name*

Telephone*

Employer Name*

Start*

End*

Employer Address*

Reason for Leaving*

Supervisor Name*

Telephone*

STAY INFORMED

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312 N. 4th Street, Clarksburg WV 26301
(304) 622-2451
admin@clarksburgmission.org