Intake Assessment - Clarksburg Mission

INTAKE ASSESSMENT FORM

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Personal Information

Potential Resident Name*

First Last

Birth Date*

Current Address*

Street Address Address Line 2 City State ZIP Code

Phone Number*

Contact Name (If different than applicant)

First Last

Emergency Contact & Release of Information (Full name, address, phone and relationship)*

l understand that the person listed above will be given any information deemedappropriate by management, in the event that it is necessary to communicate with them during my stay in this facility*

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Current Treatment Information

Current Treatment Center or Correctional Facility

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number*

Primary Counselor*

Counselor Contact Number*

Tentative Discharge Date*

Past Treatment Programs*

Substance(s) Used in Past*

Drug(s) of Choice*

Clean Date*

Income and Legal Information

Current Source of lncome*

Weekly $*

Pending Legal Matters (please explain)*

Past Legal Matters (please explain)*

Are you required to register as a sex offender?*

Yes

No

Do you have any mental health diagnoses?*

Yes

No

If yes, please explain

Do you have any physical limitations?*

Yes

No

If yes, please explain

Medical Information

Current Medication and Dosages

Miscellaneous

How did you hear about us?*

Applicant Name

First Last

Applicant Signature

Todays Date

Probation/Parole Officer

Phone Number

Which vital documents is the applicant in need of?

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