Apply for services

Service & personal details

Full name *0 / 120

Date of birth *

Pronouns (optional)0 / 60

Email address *

Phone number *0 / 10

Client address *0 / 500

Referral, insurance & emergency contact

Is there a referring party? *YesNo

Referring organization *0 / 180

Referring party email (optional)

Referring party phone (optional)

Referring party title (optional)0 / 120

Does the client have Medicaid? *YesNo

Medicaid ID *0 / 40

Can you provide an emergency contact? *YesNo

Emergency contact name *0 / 120

Emergency contact phone *

Emergency contact email (optional)

Emergency contact relationship *0 / 100

Social demographics

Do you have children? *YesNo

Are any of your children currently placed in foster care? *YesNo

Are you a veteran? *YesNo

Have you graduated high school? *YesNo

Do you have family that supports your recovery? *YesNo

History & support needs

What is the presenting problem you are working on? *0 / 2500

Have you previously been in treatment? *YesNo

When were you previously in treatment? *0 / 160

Where were you previously in treatment? *0 / 200

Age of first use (optional)

Date of last use (optional)

Length of current use (optional)0 / 160

Do you have a valid ID? *NoneIDDriver's license

Do you need transportation resources or assistance? *YesNo

Do you need dental care? *YesNo

Do you need vision care? *YesNo

Do you need assistance applying for benefits? *EBTMedicaidNone

Employment & goals

Employment status at application *EmployedUnemployed

Where are you employed? *0 / 180

Work schedule *0 / 250

Do you have an up-to-date resume? *YesNo

How can we help? *0 / 2500

PHQ-9 assessment

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things *Not at allSeveral daysMore than half the daysNearly every day

2. Feeling down, depressed, or hopeless *Not at allSeveral daysMore than half the daysNearly every day

3. Trouble falling or staying asleep, or sleeping too much *Not at allSeveral daysMore than half the daysNearly every day

4. Feeling tired or having little energy *Not at allSeveral daysMore than half the daysNearly every day

5. Poor appetite or overeating *Not at allSeveral daysMore than half the daysNearly every day

6. Feeling bad about yourself, or that you are a failure or have let yourself or your family down *Not at allSeveral daysMore than half the daysNearly every day

7. Trouble concentrating on things, such as reading the newspaper or watching television *Not at allSeveral daysMore than half the daysNearly every day

8. Moving or speaking so slowly that other people could have noticed, or so fidgety or restless that you have been moving a lot more than usual *Not at allSeveral daysMore than half the daysNearly every day

9. Thoughts that you would be better off dead, or thoughts of hurting yourself in some way *Not at allSeveral daysMore than half the daysNearly every day

GAD-7 assessment

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Feeling nervous, anxious, or on edge *Not at allSeveral daysMore than half the daysNearly every day

2. Not being able to stop or control worrying *Not at allSeveral daysMore than half the daysNearly every day

3. Worrying too much about different things *Not at allSeveral daysMore than half the daysNearly every day

4. Trouble relaxing *Not at allSeveral daysMore than half the daysNearly every day

5. Being so restless that it is hard to sit still *Not at allSeveral daysMore than half the daysNearly every day

6. Becoming easily annoyed or irritable *Not at allSeveral daysMore than half the daysNearly every day

7. Feeling afraid as if something awful might happen *Not at allSeveral daysMore than half the daysNearly every day

Review & submit

Please check your answers. Use Previous to make changes before submitting.

Request for Services Assessment

Call

Email

address