Region 8 A&D SCREENING Full Name: Date: Date of Birth: Gender: Male Female Phone: County of Residence: Backup Phone: What modality are you interested in? -- Select an option -- Not Sure IOP Residential for Male Residential for Female Do you live in Rankin, Copiah, Simpson, Madison, or Lincoln counties? Yes No If outside, did you contact your area's mental health facility? Yes No If yes, who did you talk to and what did they tell you? Income & Support Details: Are you pregnant? Yes No If pregnant, how many months? Receiving Prenatal Care? Yes No Drugs used in the last month: How long have you been using? Method of use: Court-ordered to treatment? Yes No If yes, what court/judge? Have you been arrested? Type of insurance: Previously received services from Region 8? Yes No Currently prescribed medications: Any medical conditions? Last doctor's visit: Emergency contact for medical transport: Submit Back to A and D Page
