Pre-Screen Assessment Form Are you filling out this information for yourself or someone else in need of The Extension Program. For Myself For Someone Else Caller InformationPlease fill out the “Caller Information” section, the assessment questions and submit the form. Our admissions team will contact you the following business day.Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Race(Required)Please Select OneAsianAmerican-Indian or Alaska NativeBlack or African AmericanHispanicNative Hawaiian or Other Pacific IslanderMiddle Eastern or North AfricanWhiteTwo or More RacesOther RaceUnknownDeclined To SpecifyDemographic information is being voluntarily obtained for data collection purposes only.Gender(Required)Please Select OneMaleFemaleTransgenderGender NeutralNon-BinaryAgenderPangenderGenderqueerThird GenderTwo SpiritsPhone(Required)Email Are you seeking substance use treatment for drugs and/or alcohol?(Required) Yes No What is your drug of choice?(Required)Are you a registered sex offender, in the process of registering as a sex offender, or might have to potentially register as a sex offender in the future?(Required) Yes No Unfortunately, at this time you do not meet criteria for admission. Please see below for a list of resources. Addiction & Recovery Substance Abuse & Mental Health Services Administration (SAMHSA) Phone: 1-800-662-HELP Website: samhsa.gov/find-help Ascensa Health (Formerly St. Jude’s Recovery Center) Phone: (404) 874-2224 Website: ascensahealth.org Highland Rivers Behavioral Health Phone: 1-800-729-5700 or 770-429-5000 Website: highlandrivers.org MARR Addiction Treatment Centers (Men & Women) Phone: 678-679-4909 Website: marrinc.org Mary Hall Freedom House Phone: 770-642-5500 Website: maryhallfreedomvillage.org THOR Approved Programs Website: THOR Directory Four Winds Recovery Phone: 404-957-6765 Website: 4windsrecovery.com GARR Directory Website: thegarrnetwork.org United Way Call: 211 Website: wuw.org Housing MUST Ministries Phone: 678-218-4531 Website: mustministries.org The Center for Family Resources Phone: 770-428-2601 Website: thecfr.org Caring Works Phone: 404-371-1230 Website: caringworksinc.org Atlanta Mission Phone: 404-588-4007 Website: atlantamission.org City of Refuge Phone: 404-874-2241 Website: cityofrefugeatl.org Salvation Army (Atlanta) Phone: 404-476-2700 Website: salvationarmyatlanta.org LiveSafe Phone: 770-427-3390 Website: livesaferesources.org Cobb Homeless Alliance Phone: 770-575-5785 Website: gahomeless.org Gateway Center Phone: (404) 215-6600 Website: gatewayctr.org Mental Health Georgia Crisis & Access Line (GCAL) Call/Text/Chat: 988 National Suicide Prevention Lifeline Phone: 1-800-273-8255 Cobb Behavioral Health Crisis Center Phone: (404) 794-4857 Website: highlandrivers.org WellStar Kennestone Hospital Phone: 770-793-5000 Website: wellstar.org Ridgeview Institute Phone: (844) 350-8800 Website: ridgeviewinstitute.com Peachford Hospital Phone: (770) 455-3200 Website: peachford.com Willowbrooke at Tanner Phone: 770-812-9551 Website: tanner.org Twin Lakes Recovery Center Phone: 800-588-5967 Website: twinlakesrecoverycenter.com Black Bear Lodge Phone: 833-658-4500 Website: blackbearrehab.com Blue Ridge Mountain Recovery Phone: 678-648-1756 Website: blueridgemountainrecovery.com Exit to Homepage AssessmentHow did you hear about us?(Required)Please Select OneFamilyFriendAlumniWord of MouthInternetReferred from(Required)(Name of organization or individual)What program are you calling about?(Required) Men's Women's What type of program are you seeking?(Required)Please Select OneInpatientOutpatientDetoxResidentialShelterMental HealthCrisis/StabilizationHousing OnlyDrug and Alcohol EvaluationSober LivingAre you homeless?(Required) Yes No Where did you sleep last night?(Required)Do you know the ZIP code you are calling from?(Required) Yes No What ZIP code are you calling from?(Required)ZIP CodeDo you know the city and state you are calling from?(Required) Yes No What city and state are you calling from?(Required) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State What county are you calling from?(Required)CountyDo you know the ZIP code of your last permanent address?(Required) Yes No What is/was the ZIP code of your last permanent address?(Required)ZIP CodeDo you know the city and state of your last permanent address?(Required) Yes No What is/was the city and state of your last permanent address?(Required) City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State What is/was the county of your last permanent address?(Required)CountyAre you a current IV user?(Required) Yes No Mental Health Issues: Are you taking any medications for emotional or psychological necessities?(Required)For example, but not limited to this list: Psychotropics, mood stabilizers, anti-anxiety, or anti-depression medications? Medications may include (but are not limited to): Ativan, Celexa, Cymbalta, Desyrel, Effexor, Lexapro, Prozac, Wellbutrin, Xanax, Zoloft, etc Yes No Please list medication(s):(Required)Physical Issues: Are you taking any medications for medical necessities?(Required)For example, but not limited to this list: HTN, liver disease, diabetes, heart disease, ulcers, asthma, chronic pain, any surgeries in the past 5 years, etc... Yes No Please list medication(s):(Required)Are you supposed to be taking medications?(Required) Yes No What was the diagnosis? What medication are you supposed to be taking?(Required)Do you have any children?(Required) Yes No If they are 17 years or younger, who has custody of them at this time?(Required)Are you pregnant?(Required) Yes No Are you incarcerated?(Required) Yes No Attorney/Public Defender and correctional facility information:Do you know your release date?(Required) Yes No What is your release date?(Required) MM slash DD slash YYYY Do you have any pending charges?(Required) Yes No Please list the charges:(Required)Are you able to work?(Required) Yes No ADL's: Activities of daily living:(Required)Are you able to Feed, Toilet, Clothe and Bath yourself? Can you manage your meds if necessary? Yes No If no, please list the issue(s):(Required)Will you commit to a 12-month program?(Required) Yes No CommentsResources Addiction & Recovery Substance Abuse & Mental Health Services Administration (SAMHSA) Phone: 1-800-662-HELP Website: samhsa.gov/find-help Ascensa Health (Formerly St. Jude’s Recovery Center) Phone: (404) 874-2224 Website: ascensahealth.org Highland Rivers Behavioral Health Phone: 1-800-729-5700 or 770-429-5000 Website: highlandrivers.org MARR Addiction Treatment Centers (Men & Women) Phone: 678-679-4909 Website: marrinc.org Mary Hall Freedom House Phone: 770-642-5500 Website: maryhallfreedomvillage.org THOR Approved Programs Website: THOR Directory Four Winds Recovery Phone: 404-957-6765 Website: 4windsrecovery.com GARR Directory Website: thegarrnetwork.org United Way Call: 211 Website: wuw.org Housing MUST Ministries Phone: 678-218-4531 Website: mustministries.org The Center for Family Resources Phone: 770-428-2601 Website: thecfr.org Caring Works Phone: 404-371-1230 Website: caringworksinc.org Atlanta Mission Phone: 404-588-4007 Website: atlantamission.org City of Refuge Phone: 404-874-2241 Website: cityofrefugeatl.org Salvation Army (Atlanta) Phone: 404-476-2700 Website: salvationarmyatlanta.org LiveSafe Phone: 770-427-3390 Website: livesaferesources.org Cobb Homeless Alliance Phone: 770-575-5785 Website: gahomeless.org Gateway Center Phone: (404) 215-6600 Website: gatewayctr.org Mental Health Georgia Crisis & Access Line (GCAL) Call/Text/Chat: 988 National Suicide Prevention Lifeline Phone: 1-800-273-8255 Cobb Behavioral Health Crisis Center Phone: (404) 794-4857 Website: highlandrivers.org WellStar Kennestone Hospital Phone: 770-793-5000 Website: wellstar.org Ridgeview Institute Phone: (844) 350-8800 Website: ridgeviewinstitute.com Peachford Hospital Phone: (770) 455-3200 Website: peachford.com Willowbrooke at Tanner Phone: 770-812-9551 Website: tanner.org Twin Lakes Recovery Center Phone: 800-588-5967 Website: twinlakesrecoverycenter.com Black Bear Lodge Phone: 833-658-4500 Website: blackbearrehab.com Blue Ridge Mountain Recovery Phone: 678-648-1756 Website: blueridgemountainrecovery.com
