Planting Hope

Planting Hope Admission Screener

Admissions Screening

First Name

Last Name

Date of Birth

Is the individual seeking treatment for a substance use concern? *

Yes No

Is the Individual age 18 or older? *

YesNo

Is the individual currently experiencing and urgent medical or withdrawal-related concerns requiring immediate attention? *

YesNo

Is the individual experiencing any thoughts of suicide or wishing they were dead? *

YesNo Unable to determine

Is the individual experiencing any thoughts of, or engaging in, non-suicidal self-harm (e.g., cutting, burning, scratching without intent to die)? *

Yes No Unknown/Declined

Is the individual currently pregnant?

YesNo Not Applicable Unknown/Declined

What substances does the individual currently use or have a history of using? *

Alcohol Opioids StimulantsCannabisBenzodiazepines NicotineOther

Where is the individual currently living? *

Stable/permanent housing Temporary housing/Sober living Shelter Unhoused/no current residenceOther Unknown

What is the individual's current residential address?

Street

Address 2

City *

State

Postal Code

Does the individual have reliable transportation to attend treatment appointments? *

YesNo Sometimes/Unreliable Unknown/Declined

Does the individual have reliable access to a phone for treatment-related communication? *

Yes No SometimesUnknown/Declined

Does the individual currently have mental health or behavioral health concerns that may affect treatment? *

YesNo Unknown/Declined

Does the individual currently have supportive people or recovery supports available to them? *

YesNo Limited/unreliableUnknown/declined

Does the individual have any current legal, probation, parole, or court-related requirements related to treatment?

YesNo Unknown/Declined

Is there any other information from the screener that may affect the individual's admission or need for referral? *

YesNoUnknown/Declined

Does the individual have any current medical conditions, medications, or other health concerns that may be relevant to treatment? *

Yes No Unknown/Declined

Does the individual have any safety concerns other than those already identified above? *

YesNo Unknown/Declined

Does the individual have any current employment, education, or financial concerns that may affect treatment or recovery? *

YesNo Unknown/Declined

Does the individual need any language, communication, or accessibility accommodations to participate in treatment? *

YesNo Unknown/Declined

Does the individual have any dietary, cultural, religious, or other personal needs that should be considered in tretament? *

YesNo Unknown/Declined

Does the person have any current barriers not listed that could interfere with participating in outpatient treatment?

Yes No Unknown/Declined

Is the individual currently receiving substance use disorder treatment or services fromanother provider? *

Yes No Unknown/Declined

Is the individual willing and able to participate in outpatient treatment and attend scheduled appointments? *

Yes No Unsure

Does the individual have any current concerns about participating in telehealth, if telehealth services are needed? *

Yes No Unsure

Is there any other information the individual would like to share that may be relevant to their treatment or admission? *

Yes No