ADMISSION SCREENING FORM

SANTA MARIA HOSTEL, INC.

SCREENING FORM
Today's Date*

MonthDayYear
Date
Name*

First NameLast 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 TreatmentDetoxOutpatientMedication Assisted TreatmentCOPSD ServicesUnsureOther
Gender: How do you identify?

WomanNon-BinaryTransgenderOther
Do you have a valid ID or Drivers License?*

YesNo
Do you have a Social Security Card?*

YesNo
Do you have private insurance, Medicaid, or Medicare?*

YesNoUnsure
If you have insurance please enter the information below:*
Ethnicity*

African AmericanAsianCaucasianHispanicNative AmericanOther
Marital Status*

SingleMarriedOther
Do you have dependent children under the age of 18?*

YesNo
Are you interested in brining your children to treatment with you?

YesNoUncertain
If yes, what are the names and ages of your dependent children?
Are your children in foster care or in care of another person?*

YesNoNot Applicable
Are you currently involved with CPS?*

YesNo
If yes, please provide the name, phone number, and/or email address of your CPS worker:*
Are you currently on probation or parole?*

YesNo
If yes, please provide the name, phone number, and/or email address for your P.O.?*
Are you pregnant?*

YesNoUnsure
If yes, what is your due date?*

MonthDayYear
Date
Have you had prenatal care?*

YesNo
Are you currently experiencing housing instability or homelessness?

YesNo
Please provide some additional information to help us determine eligibility for specialized specialized services we offer.
Are you a veteran?*

YesNo
Are you a victim of Prostitution?*

YesNo
Are you a victim of Human Trafficking?*

YesNo
Are you a registered sex offender?*

YesNo
When was the last date you used any substances including alcohol?*

MonthDayYear
Date
Are you currently injecting a substance?*

YesNo
What substances have you used in the past 30 days? (Check all that apply)*

*AlcoholAmphetamineBath SaltsCocaine/Crack*Codeine (Tabs or Syrup)*Darvocet*Dilaudid*DemerolEcstasy*Heroin*HydrocodoneInhalantsKushMarijuanaMethamphetamine (Meth, Speed, Ice, Shards, Bikers Coffee, Stove Top, Tweak, Yaba, Chalk, Crystal, Crank).*Morphine*Opium*Oxycodone*OxyContinPCP*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.
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 XRMethylphenidate (Concerta, Quillvant XR, Ritalin)Dextroamhetamine (Dexedrine)Lisdexamfetamine (Vyvanse)Atomoxetine (Strattera)NoneOther
Are you currently taking any of the following medications?*

Buprenorphine (Suboxone, Subutex)MethadoneNaltrexoneDisulfiram (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.*

YesNo
Signature
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.
We have recently moved our intake screening form.

Please visit the link here to start the admission process.
If you are in need of immediate help for a psychiatric emergency please call 911 or the NeuroPsychiatric Center (NPC) at 713-970-7070.
Should be Empty:

SANTA MARIA HOSTEL, INC.

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

Thank you

We have recently moved our intake screening form.

Please visit the link here to start the admission process.