SCREENING FORMDate of Screening *Source of Referral: *Personal InformationName *FirstMiddleLastAliasEmailClient's Address *Address Line 1Address Line 2CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeMove in Date:Current Living Situation: *Non-Housing (street/park/car/bus station/etc.)Emergency ShelterTransitional housing for homeless personsHospitalPsychiatric FacilityJail/PrisonSubstance Abuse Treatment FacilityLiving w/ relatives/friendsRental HousingOwned HousingOtherPrevious Living Situation: *Non-Housing (street/park/car/bus station/etc.)Emergency ShelterTransitional housing for homeless personsHospitalPsychiatric FacilityJail/PrisonSusbtance Abuse Treatment FacilityLiving with relatives/friendsRental housingOwned HousingOtherRace: *Alaskan NativeAmerican IndianAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderOther Single RaceTwo or More RacesWhiteDecline to Specify Gender Identity: *MaleFemaleTrans-MaleTrans-FemaleHeight: *Weight: *Eye Color: *Hair Color: *Date of Birth: *Sex at Birth *MaleFemaleUnknownMarital Status *Never MarriedMarriedCohabitatingWidowedDivorced/Separated w/ Custody of KidsDivorced/Separated w/out Custody of KidsUnknownSocial Security Number: *Citizen: *US CitizenNot a US CitizenPrimary Phone Number: Alternate Phone Number: Drivers License Status: *ValidNot ValidDrivers License Number:Driver's License State of issueMother’s Maiden Name: *Client's Birth City and State: *Religious Preference: *UnknownRoman CatholicProtestantBaptistPentecostalMethodistPresbyterianJewishMuslimBuddhistHindu Christian ScientistJehovah’s WitnessAtheistNon-DenominationalOtherU.S. Veteran: *YesNo________________________________________________________Health Insurance Company: ________________________________________________________Legal HistoryCurrent Charge: *Charge Type (if applicable):Civil/PetitionFelonyMisdemeanorOtherStatus Offense (JuvenileIncident Offense (if applicable): New Criminal OffenseNew PetitionParole Violation TechnicalParole Violation New Criminal ChargeProbation Violation New Criminal Offense Probation Violation TechnicalArrest Date (if applicable): Arraignment/ First Appearance Date (if applicable):Have you been Sentenced? (if applicable): YesNoSentence (if applicable):Jail Status (if applicable):DetentionJailNot In DetentonNot In JailDo You Have Prior Convictions? : *YesNoIf Yes, What are they?# of Felonies (if applicable):# of Misdemeanors (if applicable):Have you ever had Child Protective Service Activity? *YesNOIf Yes, Why?Current Charge or Previous Conviction of a Violent Crime or Sex Offense, Other than Domestic Violence? *YesNOIf Yes, what?Previous Conviction for Domestic Violence? *YesNoOutstanding Warrants? *YesNoCurrently on Probation? *YesNoIf Yes, Probation Officer's Name:currently on Parole? *YesNoIf Yes, Parole Officer’s Name:Are There Pending Criminal Charges? *YesNoHistory of Previous Court Failures to Appear: *None123 or moreHistory of Previous Drug Court/ Drug Treatment: *None Successfully CompletedTransferred to another JurisdictionUnsuccessful – AbscondedUnsuccessful – New Offense Unsuccessful – Program ViolationVoluntary Withdrawal ________________________________________________________Substance Abuse HistoryPrior Substance Abuse: *YesNODrug of Choice:Second Drug of Choice:Third Drug of Choice:Prior Substance Abuse Treatment: *YesNoIV Drug User? *YesNoAge Began Using Drugs:Years Using Drugs:Age Began Using Alcohol: Years Using Alcohol:Are you Currently in a Substance Abuse Treatment Program? *YesNo________________________________________________________Medical/Mental Health HistoryAre you on any Current Medications? *YesNoIf Yes...For a Physical ConditionFor a Psychological ConditionFor BothWhat Are Your Current Medications? *Are You Pregnant?: *YesNoIf Yes, Due Date:Comments:________________________________________________________Educational History:Highest Education Completed: *Current Educational Status: *________________________________________________________Employment HistoryCurrent Employment Status: *UnemployedEmployed Full-TimeEmployed Part-TimeNot in Labor ForceIf Employed, Name of Current Employer:Primary Source of Support: *Adoption SubsidyDisabilityFamilyFoster Care SubsidyRetirement PlanSalary/Wages Social Security Social Security DisabilityVeteran’s BenefitsWelfareWorkers Compensation Other NoneGross Monthly Income (from all sources): *________________________________________________________MiscellaneousTransportation Status: *Reliable TransportationNo Reliable TransportationNumber of Children *Number of Dependent Children *Current Child Support: *N/APaying, CurrentPaying, Not CurrentNot PayingChild Custody Status: *N/ATemporarily Lost CustodyRegained CustodyParental Rights Terminated Never Lost Custody ________________________________________________________Emergency Contact Name: *Emergency Contact Phone Number: *WebsiteSubmit