Revised April 1, 2015 Page 1 of 5

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1 Interview Date: Community Treatment Center 1215 Lake Drive Cocoa, Florida Phone: Fax: Do you have a substance abuse problem? Yes No Do you have a mental health diagnosis? Yes No Have you ever used IV drugs? Yes No Are you currently pregnant? Yes No Personal information: Community Treatment Center SCREENING/ADMISSION APPLICATION Name: Date of Birth: Social Security Number : ( leave blank if you do not have one) Do you have your card: Yes No Address: (If you do not have one leave blank) Contact Number: Military/Branch of Service: Are you a United States Citizen? Yes No Place of Birth: Do you have a valid Driver s license? Yes No If not why? _ If no Driver s License do you have ID? Yes No If no ID, what do you need to do to get one? _ Sex: Male Female Race: Physical handicaps: Married Never Married Separated Divorced Do you receive Medicaid/Medicare: Yes No Revised April 1, 2015 Page 1 of 5

2 How many children do you have? Ages of Children: Are your children currently involved with DCF, welfare system or other services? Yes No Please list: If DCF involvement, please list Workers Name: Any other pertinent information about children such as where the children are place/with whom: Psychiatric History Have you ever been in counseling or had counseling for mental health issues? Yes No If yes, where/who: Reason Dates of Treatment: Are you currently on any medications: Yes No If yes, what? Have you ever been diagnosed with a mental health disorder? Yes No If YES, list all diagnosis given: Have you ever been prescribed medication for a mental health disorder? Yes No If YES, list previous medications: _ Have you ever had any suicide attempts? Yes No if yes, when? Describe: Have you ever needed help with your emotional problems or told someone you needed help? Yes No Have you ever been told you have a mental health issue or have you been experiencing anxiety, depression, hearing voices or any other emotional problems? Yes No Substance Abuse History Do you drink alcohol? Yes No Have you ever experimented with drugs? Yes No Have you ever felt you ought to cut down on your drinking or drug use? Yes No Have people annoyed you by criticizing your drinking or drug use? Yes No Have you ever felt bad or guilty about your drinking or drug use? Yes No Have you ever had a drink or used drugs first thing in the morning to steady your nerves or rid of a hangover? Yes No get Substance Age use began Frequency Administered Date last use Revised April 1, 2015 Page 2 of 5

3 Hallucinogens: Marijuana: K-2 Opiates: Heroin Dilaudid Lortab Oxy: Oxycodone OxyContin Percocet Roxicet Alcohol: Benzodiazepines: Valium Xanax Librium Cocaine: Crack Other: XTC, Meth, PCP Suboxen Substance Abuse Treatment History Facility Name Residential/Outpatient Dates at Facility Outcome Longest period of sobriety? What precipitated relapse? Drug of Choice: (1) (2) (3) Are you an IV drug User? Yes No Any other substance abuse information not asked? Revised April 1, 2015 Page 3 of 5

4 Our Staff is committed to help you deal with any substance abuse and/or emotional problems you may have, but we can only do this if we are aware of your problems. Please list any further information that we did not ask that you would think could be helpful: Education Highest Grade Completed: (1-12 years) College (1-4 years) Post-Grad (1-4 years) Degree: (including HS diploma, GED, vocational certificates, college or other achievements): Legal History Do you currently have a legal problem? Yes No Do you have a case pending? Yes No If yes to either question, please explain: Are you currently on probation? Yes No Community Control? Yes No If yes, please state Probation Officer s name: Have you been to prison? Yes No how long? For what? Medical History Do you have present or past medical issues? Yes No If yes, please describe: Employment History Do you currently work? Yes No If yes, where? If no, please list where and when you last worked: Are you able and willing to work? Yes No if not, please explain: *Please note it is MANDATORY you seek and gain employment if accepted into our residential program Interviewers comments: Revised April 1, 2015 Page 4 of 5

5 I AM CAPABLE OF SELF PRESERVATION: To the best of my knowledge that above is true and accurate. If it is found that any part of your application is not true, you are running the risk of not being accepted into Community Treatment Center, or being discharged if you have been accepted. If any changes with the above information, you will notify staff immediately prior to admission. (Please sign and date under screening section only) Screening Admission Applicants signature Date Applicants signature Date Interviewers Signature Date Intake Staff Signature Date Staff Use ONLY Admission Type Decision on Services Not in need of services Y / N Appropriate for services Y / N Voluntary Competent Involuntary Competent Not appropriate for services at Y / N screening site Voluntary Incompetent Involuntary Incompetent Appropriate for referral elsewhere Y / N Revised April 1, 2015 Page 5 of 5

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