Quick Screening Posted on July 31, 2012May 30, 2016 by Matt C2R Quick Screening The following information is kept strictly confidential and protected by federal law. We cannot release any information shared without your written permission. Name First Last Date Date of Birth Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneHow would you like us to communicate with you?*PhoneEmailBothWhich substances have you recently used? (Substance / Last Time Used / How Much) (If alcohol is there any other drug usage?)Are you currently experiencing any withdrawal symptoms (i.e. sweating, nausea, intestinal distress):NoYesIf yes, list symptoms: Have you ever been in treatment for drugs/alcohol?NoYesPlease explain: Do you have a previous or current mental health diagnosis?NoYesIf yes, list current diagnosis and medications being taken: Level of computer literacyBeginnerIntermediateAdvancedType of AssesmentVideo ConferenceFace To FaceHow Did You Hear About Us? Convenient Group ScheduleDayEveningWhy are you choosing online vs face to face? This service is only currently available to those who are twenty-one (21) years of age or older
