Project Success Intake "*" indicates required fields Step 1 of 14 7% Personal InformationFull name* Preferred Name* Date of Birth* MM slash DD slash YYYY Gender*MaleFemalePronouns* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone Number*Marital Status* Race Ethnicity Religion Email* Emergency Contact Name* Emergency Contact Phone Number*Relationship to Emergency Contact* Referral InformationReferred By (if applicable) Contact Information of Referrer Reason for Referral Substance Use HistoryPrimary Substance(s) Used* Frequency and Quantity of Use* Age of first Use* Last Date of Use* MM slash DD slash YYYY Route of Administer* Previous Attempts to Reduce or Quit (if any) Current Medications for Substance Use (if any) Overdose History Number of Overdoses Dates of Overdoses MM slash DD slash YYYY Medical HistoryCurrent Medical Conditions Past Medical Conditions Medications Allergies Primary Healthcare Provider Name Contact Information Mehavioral Health Diagnoses (if any) Mehavioral Health Medications Current Mehavioral Health Provider Name Contact Information Last physical Exam Do you need a referral to see a physician for a physical?*YesNo Family Medical HistoryHeart Disease Diabetes Cancer Other Significant Conditions General Health QuestionsRecent Injuries/Surgeries Mobility Issues Vision/Hearing Problems Preventive CareVaccinations: up-to-date (including annual flu vaccine) Pain Assessment ToolPain locationHeadNeckShoulders (RT, LT, BILATERAL)Arms (RT, LT, BILATERAL)Hands (RT, LT, BILATERAL)GroinHips (RT, LT, BILATERAL)Legs (RT, LT, BILATERAL)Foot (RT, LT, BILATERAL)Pain is worseMorningAfternoonEveningNightOnset of painAcute- 48 hours- 6 monthsChronic- longer than 6 monthsPain feels better when Pain feels worse when Patient Description of Pain- Check all that apply Sharp Tingles Throbbing Dull Stings Burning Ache Tender Other Does the pain radiate? Patient Unable to describe/respond Pain scale: Intensity (1-6 with 6 being worst pain)123456 Nutrition AssessmentFood Allergies (Confirmed or suspected) Please listHave you lost or gain 10 pounds or more in the last 3 months?YesNoHow much? Do you have a decrease in food intake and/or appetite?YesNoDo you have any Dental problems?YesNoEating habits or behaviors that may be indicators of an eating disorder,BingeingInducing vomitingPurging (use laxatives frequently)Do you avoid family dinners and social events involving food? Social HistoryLiving SituationHomelessLiving with Family/FriendsOwn/Rent HousingOther (please specify)Other living situation Employment StatusEmployedUnemployedStudentOther (please specify)Other employment status Source of IncomeLegal Issues (if any):NoneProbationParolePending ChargesOther (please specify)Other legal issue Support SystemFamily Support*YesNoFriends/Peer Support*YesNoInvolvement in Community or Support Groups*YesNoCommunity Support Groups Detail Suicide ScreeningIn the past few weeks, have you wished you were dead?*YesNoIn the past few weeks, have you felt that you or your family would be better off if you were dead?*YesNoIn the past week, have you been having thoughts about killing yourself?*YesNoHave you ever tried to kill yourself?*YesNoHow Are you having thoughts of killing yourself right now?*YesNoHave you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?* Goals and PreferencesImmediate Needs* Short-Term Goals* Long-Term Goals* Initial Screening Completed By Date of Screening MM slash DD slash YYYY Accepted into ProgramYesNoIf No, Reason* Date of Intake Completion MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.
