MEDICAID SCREENING

Full Name*
First Last
Date of Birth
Medicaid ID number
Best number to reach you at
Email address*
Do you have outside support?*
Aside from treatment
Do you have any sex offense charges?*
Do you have a way to pay for your co-pay’s for medication?*
The card will be needed before entering treatment
Recent treatment stays in the last 90 days? If so where?
Have you been incarcerated in the last 90 days?*
Do you have any court dates in the next 60 days? If so do you have family that will transport you there and back?*
Are you on probation or parole? If yes, are you court ordered to treatment?*
Past or present mental health diagnosis? If so what was it and who gave you the diagnosis?*
Are you going to need to detox? If so off of what?*
What have you used in the last 2 weeks? How much? How often?*
Do you have any medical issues that would get in the way of participating in treatment?*
Are you on any medications? If so, what are they? What dose?*
Do you plan on going to sober living after treatment? If so where and how will you be paying for it?*