Screening Form – Carson City Community Counseling Center

Date of Screening *

Source of Referral: *

Personal Information

Name *

First

Middle

Last

Alias

Email

Client's Address *

Address Line 1

Address Line 2

City

State

Zip Code

Move in Date:

Current Living Situation: *

Previous Living Situation: *

Race: *

Gender Identity: *

Male
Female
Trans-Male
Trans-Female

Height: *

Weight: *

Eye Color: *

Hair Color: *

Date of Birth: *

Sex at Birth *

Male
Female
Unknown

Marital Status *

Social Security Number: *

Citizen: *

US Citizen
Not a US Citizen

Primary Phone Number:

Alternate Phone Number:

Drivers License Status: *

Valid
Not Valid

Drivers License Number:

Driver's License State of issue

Mother’s Maiden Name: *

Client's Birth City and State: *

Religious Preference: *

U.S. Veteran: *

Yes
No

________________________________________________________

Health Insurance Company:

________________________________________________________

Legal History

Current Charge: *

Charge Type (if applicable):

Incident Offense (if applicable):

Arrest Date (if applicable):

Arraignment/ First Appearance Date (if applicable):

Have you been Sentenced? (if applicable):

Yes
No

Sentence (if applicable):

Jail Status (if applicable):

Detention
Jail
Not In Detenton
Not In Jail

Do You Have Prior Convictions? : *

Yes
No

If Yes, What are they?

# of Felonies (if applicable):

# of Misdemeanors (if applicable):

Have you ever had Child Protective Service Activity? *

Yes
NO

If Yes, Why?

Current Charge or Previous Conviction of a Violent Crime or Sex Offense, Other than Domestic Violence? *

Yes
NO

If Yes, what?

Previous Conviction for Domestic Violence? *

Yes
No

Outstanding Warrants? *

Yes
No

Currently on Probation? *

Yes
No

If Yes, Probation Officer's Name:

currently on Parole? *

Yes
No

If Yes, Parole Officer’s Name:

Are There Pending Criminal Charges? *

Yes
No

History of Previous Court Failures to Appear: *

None
1
2
3 or more

History of Previous Drug Court/ Drug Treatment: *

________________________________________________________

Substance Abuse History

Prior Substance Abuse: *

Yes
NO

Drug of Choice:

Second Drug of Choice:

Third Drug of Choice:

Prior Substance Abuse Treatment: *

Yes
No

IV Drug User? *

Yes
No

Age Began Using Drugs:

Years Using Drugs:

Age Began Using Alcohol:

Years Using Alcohol:

Are you Currently in a Substance Abuse Treatment Program? *

Yes
No

________________________________________________________

Medical/Mental Health History

Are you on any Current Medications? *

Yes
No

If Yes...

For a Physical Condition
For a Psychological Condition
For Both

What Are Your Current Medications? *

Are You Pregnant?: *

Yes
No

If Yes, Due Date:

Comments:

________________________________________________________

Educational History:

Highest Education Completed: *

Current Educational Status: *

________________________________________________________

Employment History

Current Employment Status: *

Unemployed
Employed Full-Time
Employed Part-Time
Not in Labor Force

If Employed, Name of Current Employer:

Primary Source of Support: *

Gross Monthly Income (from all sources): *

________________________________________________________

Miscellaneous

Transportation Status: *

Reliable Transportation
No Reliable Transportation

Number of Children *

Number of Dependent Children *

Current Child Support: *

N/A
Paying, Current
Paying, Not Current
Not Paying

Child Custody Status: *

________________________________________________________

Emergency Contact Name: *

Emergency Contact Phone Number: *