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 OneWhiteAfrican AmericanAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific IslanderMiddle Eastern or North AfricanHispanicMulti-RacialPrefer Not to AnswerDemographic information is being voluntarily obtained for data collection purposes only.Gender(Required)Please Select OneMaleFemaleTransgenderGender NeutralNon-BinaryAgenderPangenderGenderqueerThird GenderTwo SpiritsPhone(Required)Email 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 seeking substance use treatment?(Required) Yes No What is your drug of choice?(Required) Are 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 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 a registered sex offender or are you in the process of registering as a sex offender?(Required) Yes No 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 9-12 month program?(Required) Yes No CommentsReferrals SectionSubstance Abuse Treatment(Required)Please Select One...Four Winds RecoveryAgape HouseAscensa Health at St. Jude's Recovery CenterAtlanta MissionThe ZoneCaring Works, Inc.GilgalLaurelwood Treatment FacilitySubstance Abuse Treatment(Required)Please Select One...Mary Hall Freedom HouseMothers Making a ChangeMount Sinai Wellness CenterRight Side Up (MARR)Sunrise DetoxSubstance Abuse and Mental Health Services Administration (SAMHSA)THOR ListGA Council on Substance Abuse (Peer Support & Hotline)Substance Abuse Insurance Required(Required)Please Select One...Twin LakesBlue RidgeRiverWoods Behavioral Health LodgeWillowbrooke at TannerA.C.E. Community Support Services Are you seeking housing assistance referrals?(Required) Yes No Housing Shelter Refferral(Required)Please Select One...Salvation ArmyGood Neighbor Homeless ShelterHOPE AtlantaLiveSafeMarietta Homeless AuthorityMarietta Housing AuthorityMUST MinistriesThe Center for Family ResourcesCobb Street MinistriesAtlanta Housing Authority Are you seeking mental health assistance referrals?(Required) Yes No Mental Health Refferral(Required)Please Select One...Twin LakesMount Sinai Wellness CenterRight Side Up (MARR)RiverWoods Behavioral Health LodgeSunrise DetoxWillowbrooke at TannerDomestic Violence Women's Resource CenterCobb Stabilization Unit (Part of the CSB)North Georgia CounselingCobb Community Services BoardHighland Rivers (Services Cover 12 Counties)Substance Abuse and Mental Health Services Administration (SAMHSA)Wellstar Kennestone HospitalHighland Institute AtlantaNational Suicide Prevention LifelinePeachford HospitalRidgeview Institute