ADMISSION SCREENING FORM

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? *
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? *

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? *

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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SANTA MARIA HOSTEL, INC.

Please provide some additional information to help us determine eligibility for specialized specialized services we offer.

Thank you