Pre Screen Application Name * First Name Last Name Contact Number * Country (###) ### #### SSN * Date of Birth * MM DD YYYY Gender * Born male Born female Marital Status * Single Married Separated Divorced What level of care are you looking for? * PHP IOP OP Are you currently in a hospital / mental health facility * Y N Sobriety Date * MM DD YYYY Are you employed? * Y N Do you have a source of income? * Y N Do you have Insurance? * Y N Medicated assisted Treatment? * Y N Are you currently in another program? * Y N Are you receiving case management * Y N Are you currently homeless? * Y N Current location or address * LEGAL HISTORY Are you court ordered to treatment? * Y N Supervision? * P&P MHC DC VTC CASEY LAW N/A Officer's Name and Number * Any pending cases? * Y N Do you have any future court dates? * Y N Do you have an EPO/DVO on you? * Y N Do you have an EPO/DVO on someone else? * Y N Do you have any warrants to your knowledge? * Y N Any Violent or aggressive behaviors in the last 30 days? * Y N MENTAL HEALTH HISTORY Are you safe? * Y N Have you ever been treated / Hospitalized for mental health prior? * Have you received any mental health diognosis? * Please list any mental health medication you are taking. * Please rate for anxiety 1-10 what is the cause of that level today? * Please rate your depression 1-10 what is the cause of that level today? * Are you homicidal? * Y N Are you suicidal? * Y N Have you had any suicidal or homicidal thoughts in the past 30 days? * Do you know of any family or close friend who has attempted or committed suicide? If yes who? * Do you currently or have you had and eating disorders? if yes please explain * Have you or your family (please specify) ever had a problem with gambling? * Have you had or are currently having any hallucinations? (Audio, Visual, Textile) * Please briefly describe your trauma history. * Family History of mental health disorders? * SUBSTANCE USE HISTORY Please detail your substance use history. (to include drug of choice, how it was taken, amount, frequency, age of first use, and the date of your most recent use.) * Are you experiencing any withdrawal or post-acute withdrawal symptoms? * Y N Do you have a family history of substance use? If yes who and what did they use? * Have you been treated for substance use before? if so, how many times, when, where, and did you complete the program? * What are your triggers? * What are your coping skills? * Who is your biggest support? * MEDICAL HISTORY Do you have a primary care physician? * Y N When was the date of your last physical? * Are you pregnant? * Y N Have you had any seizures in the last 12 months? * Y N Are you currently using a CPAP machine when sleeping? * Y N Do you have dental health concerns? * Can you perform the normal activities of daily living? * Y N Are you on any medications for mental health not previously mentioned? * Do you have access to enough food to fulfil your nutritional needs? * Y N Have you gained or lost 10 LBS in the past 3 months? * Y N Do you have any allergies? * In the last 6 months have you encountered any of the following? * Bedbugs Lice Scabies None Current or Chronic medical concerns? Please be detailed. * Are you experiencing pain if so please rate it on a scale of 1 to 10 * Where is the pain located? * Do you have any bed restrictions? For what condition and is it recommended by a doctor? * Have you ever had a sponsor and worked the 12 step program? * Y N What lengths are you willing to go for your sobriety? * What is your motivation for treatment? * What goals do you want to achieve with The Lighthouse? * IF you are accepted into the program, do you have your own transportation to get here? * Y N IF you are accepted into the program do you understand that The Lighthouse is not responsible for transportation outside of Hardin county? * Y N Do you understand that there will be no controlled substance administered at The Lighthouse? * Y N Do you attest that everything you have stated here is accurate and truthful to the best of your ability? * Y N Please re-enter your name to act as your digital signature. * First Name Last Name Your screening has been submitted! Thank you for contacting the lighthouse. If you do not hear from us within Four buisness days please call us as (270) 345 0003
