Language
English (US)
SANTA MARIA HOSTEL, INC.
SCREENING FORM
Today's Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Date of Birth
*
MONTH/DAY/YEAR Example: 12/12/1900
Last four digits of Social Security Number
*
Example: XXX-XX-1234
Street Address
*
City, State, and Zip Code
*
Phone Number
*
Please provide the best phone number to contact for scheduling your admission date
Email
example@example.com
Name of agency/person that referred you to Santa Maria?
*
Please Select
Self
CPS
Family/Friend
Former client
Probation
OSAR
Internet
BCM Anti-Trafficking Program
Ben Taub
Harris Health
Harris Center/MHMRA
Houston Recovery Center
Parole
Drug Court (RIC/STAR/FMHC)
CSCD/TAIP
Other
Were you referred for or interested in a specific treatment program(s)?
*
Residential Treatment
Detox
Outpatient
Medication Assisted Treatment
COPSD Services
Unsure
Other
Gender: How do you identify?
Woman
Non-Binary
Transgender
Other
Do you have a valid ID or Drivers License?
*
Yes
No
Do you have a Social Security Card?
*
Yes
No
Do you have private insurance, Medicaid, or Medicare?
*
Yes
No
Unsure
If you have insurance please enter the information below:
*
Ethnicity
*
African American
Asian
Caucasian
Hispanic
Native American
Other
Marital Status
*
Single
Married
Other
Do you have dependent children under the age of 18?
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Yes
No
Are you interested in brining your children to treatment with you?
Yes
No
Uncertain
If yes, what are the names and ages of your dependent children?
Are your children in foster care or in care of another person?
*
Yes
No
Not Applicable
Are you currently involved with CPS?
*
Yes
No
If yes, please provide the name, phone number, and/or email address of your CPS worker:
*
Are you currently on probation or parole?
*
Yes
No
If yes, please provide the name, phone number, and/or email address for your P.O.?
*
Are you pregnant?
*
Yes
No
Unsure
If yes, what is your due date?
*
-
Month
-
Day
Year
Date
Have you had prenatal care?
*
Yes
No
Are you currently experiencing housing instability or homelessness?
Yes
No
Please provide some additional information to help us determine eligibility for specialized specialized services we offer.
Are you a veteran?
*
Yes
No
Are you a victim of Prostitution?
*
Yes
No
Are you a victim of Human Trafficking?
*
Yes
No
Are you a registered sex offender?
*
Yes
No
When was the last date you used any substances including alcohol?
*
-
Month
-
Day
Year
Date
Are you currently injecting a substance?
*
Yes
No
What substances have you used in the past 30 days? (Check all that apply)
*
*Alcohol
Amphetamine
Bath Salts
Cocaine/Crack
*Codeine (Tabs or Syrup)
*Darvocet
*Dilaudid
*Demerol
Ecstasy
*Heroin
*Hydrocodone
Inhalants
Kush
Marijuana
Methamphetamine (Meth, Speed, Ice, Shards, Bikers Coffee, Stove Top, Tweak, Yaba, Chalk, Crystal, Crank).
*Morphine
*Opium
*Oxycodone
*OxyContin
PCP
*Percocet
*Valium
*Vicodin
*Xanax
Please list any other substances have you used in the past 12 months
*
List all substances used in the past year.
Have you ever been diagnosed with a mental health disorder?
*
Yes, I am currently receiving mental health treatment somewhere else
Yes, I received mental health treatment in the past but not currently
Yes, I currently need help with my mental health
No
If you answered yes, what is your diagnosis?
*
Please provide the name of your current Mental Health Provider? (If "no" put NA) .
*
Are you taking any current psychiatric medications? (Select all that apply).
*
Citalopram (Celexa)
Escitalopram Oxalate (Lexapro)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine HCI (Paxil)
Sertraline (Zoloft)
Desvenlafaxine (Khedezla)
Desvenlafaxine Succinate (Pristiq)
Duloxetine (Cymbalta)
Levomilnacipran (Fetzima)
Venlafaxine (Effexor)
Vortioxetine (Trentellix)
Amitriptyline (Elavil)
Imipramine (Tofranil)
Nortriptyline (Pamelor)
Doxepin (Sinequan)
Bupropion (Wellbutrin)
Isocarboxazid (Marplan)
Phenelzine (Nardil)
Selegiline Transdermal System (EMSAM)
Tranylcypromine (Parnate)
Mirtazapine (Remeron)
L-Methylfolate (Deplin)
Alprazolam (Xanax)
Clonazepam (Klonopin)
Diazepam (Valium)
Lorazepam (Ativan)
Buspirone (Buspar)
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Aripiprazole (Abilify)
Asenapine (Saphris)
Cariprazine (Vraylar)
Clozapine (Clozaril)
Lurasidone (Lutuda)
Olanzapine (Zyprexa)
Questipine (Seroquel)
Risperidone (Risperdal)
Ziprasidone (Geodon)
Adderall or Adderall XR
Methylphenidate (Concerta, Quillvant XR, Ritalin)
Dextroamhetamine (Dexedrine)
Lisdexamfetamine (Vyvanse)
Atomoxetine (Strattera)
None
Other
Are you currently taking any of the following medications?
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Buprenorphine (Suboxone, Subutex)
Methadone
Naltrexone
Disulfiram (Antabuse)
Acamprosate (Campral)
None
Please list any other medications you are currently taking: (If none, write none)
*
Have you received the COVID-19 vaccine? If yes, please bring a copy with you to your admissions appointment.
*
Yes
No
Signature
Clear
Thank you
Thank you for completing this form. We look forward to supporting you on your road to recovery. A member of our admissions team will contact you to complete your screening.
If you are in need of immediate help for a psychiatric emergency please call 911 or the NeuroPsychiatric Center (NPC) at 713-970-7070.
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