4D Intake Form - Multco
Mentors Name
*
First Name
Last Name
Which program(s) is/are the client enrolled in (check all that apply)
*
Access to Recovery (ATR)
Multnomah County Contract (MCC)
Recovery Navigation Program (RNP)
Intake Assessment
Assessment to be completed at intake between mentors and new clients or clients who have been discharged and want services again.
Date
*
-
Month
-
Day
Year
Date
Clients Name
*
First Name
Last Name
Clients Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Referred By (check all that apply)
*
Self
Friend or Family
Physician
Mental Health Program
Detox Center
Drug Treatment Program
Law Enforcement
Court
Probation Officer
High School
College
Employer
Church
Recovery Community
Prefer not to say
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Client Demographics
If you are not represented, please let us know so we can include you.
What is your race/ethnicity
*
Native American
Alaskan Native
African American
White
Native Hawaiin
Pacific Islander
Middle Eastern
Slavic
Hispanic
Prefer not to say
What was your sex assigned at birth?
*
Male
Female
prefer not to say
What is your gender identity
*
Male
Female
Transgender Male
Transgender Female
Genderqueer/gender con-conforming
Two-spirit
Prefer not to say
What is your sexual orientation?
*
Heterosexual
Gay
Lesbian
Queer
Bisexual
Two-spirit
Do you have children
*
Yes, and they HAVE had a child welfare case
Yes, and they have NEVER had a child welfare case
No
Declined to answer
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Substance Use Info
Have you experienced any of these as a result of your drug/alcohol use? Check all that apply.
*
Needing to use to stop withdrawal
Tried to quit but couldn't
Tried replacing one drug for another
Hurt someone you cared about as a result of your using
Do you want alcohol and drug recovery support?
*
Yes
No
Are you currently in treatment
*
Yes
No
Decline to answer
Where
*
Have you ever received any of these services?
*
Residential or Impatient Drug Treatment
Outpatient Drug Treatment
Impatient Mental Health Treatment
Outpatient Mental Health Treatment
MAT (Medication Assisted Treatment): methadone, suboxone, etc.
None
Are you on probation or parole?
*
Yes
No
Decline to answer
On average, how frequently have you used an illicit or legal substance, or abused a prescription?
*
Multiple times per day
Once a day
Once a week to multiple times a a week (less than daily)
Once a month to multiple times a month (less than once a week)
None in the last month
What is your last day of use or clean date?
-
Month
-
Day
Year
Date
Do you use nicotine
*
Yes
No
Decline to answer
Check all that apply
*
Cigarettes
Chewing tobacco or snuff
Vape
Gum
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Education & Employment
Last grade completed in school
*
8th or below
Some high school but no diploma
High School Diploma
GED
Some College but no degree
Associates Degree
Bachelor Degree
Masters
Doctorate
Doe you want to further your education?
*
Yes
No
Not sure
Prefer not to say
Are you employed?
Yes
No
Prefer not to answer
What best describes your current work situation?
*
Full-time
Part-time
Irregular (odd jobs)
What best describes your current work situation?
*
Is currently looking for work
Is not looking for work
Whats stopping you from looking for work?
*
Parental barriers
Enrolled in a "treatment program" that restricts work
Is on SSI or SSD
Does not want/need to work
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Living Situation
Where are you currently living
*
Owned (by client) home or apartment
Rented (by client) home or apartment, without subsidy
Rented (by client) home or apartment, with subsidy
(Minor) living with family, no need to find new home
(Minor) living with family, no need to find new home
(Adult) staying with family or friends, permanent (not paying rent; if paying rent, see rented options, above)
(Adult) staying with family or friends, temporary (not paying rent; if paying rent, see rented options, above)
Permanent supportive housing
Group home or foster care
Transitional housing
Emergency shelter
Homeless/car/other site not suitable for habitation
Residential substance abuse treatment program
Residential mental health treatment program/psychiatric institution
Prefer not to say
Do you need to improve their housing situation?
*
Yes
No
prefer to say
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Health
How do you rate your overall physical health?
*
Very Poor
Somewhat Poor
Ok
Pretty Good
Great
Do you have health insurance
*
Yes
No
Prefer not to say
What kind?
*
Oregon Health Plan
Kaiser
Providence
Private, other
I have it, but I don't know what kind
Please take a picture of yourself
*
Submit
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