Initial Screening

Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

How are you presently supporting yourself?

PLease as honest as you can

PA (Public Assistance)

SSI (Social Security Insurance)

SSDI ( Social Security Disability Insurance)

UI (Unemployment Insurance)

Family/Friends

Other Supplemental Income

Do you have a current Resume?

Yes

No

I need help with my resume

Are you abstinent (from alcohol and substances)?

Yes

No

Are you currently in treatment

Yes

No

Recently Completed

Counselor Name

First Name

Last Name

Counselor Phone

(###)

###

####

Have you ever applied to ACCES

Yes

No

If Yes, When did you apply?

MM

DD

YYYY

Do you have insurance

Yes

No

I dont know

Are you being treated for psychical/medical conditions

Yes

No

Are you being treated for Psychiatric emotional conditions by a psychiatrist, psychologist, pr medical doctor?

Yes

No