Odyssey House Behavioral Health Care Screening Form
Email *
Name of the Client being Referred *
Client Date of Birth *
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DD
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What county do you live in (Prior to incarceration)  *
What is the Client's highest level of education completed? *
GENDER PREFERENCE *
Is this a CATS referral/transfer? *
FUNDING *
Who can Odyssey Contact about this Referral? *
What is the Contact Person's phone number? *
What is the Email of the Contact Person? *
Please Select an appropriate CATEGORY *
Please select a PRIORITY level
What is the client's level of proficiency with ENGLISH?
 *
What DRUGS/ALCOHOL has the client used IN THE LAST 6 MONTHS (or prior to INCACERATION) *
Required
When was the client's LAST DATE of USE?  *
MM
/
DD
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YYYY
What SUBSTANCE(s) has the client USED IN THE LAST WEEK? *
Is this Client currently on MAT? *
Is the Client PREGNANT? *
Required
Has the client attempted suicide IN THE LAST 30 DAYS? *
Required
Is the Client on ANY TYPE OF REGISTRY? *
Required
Does the Client have or had ANY OF THESE DIAGNOSIS?  *
Required
Please ask the client "Have you ever felt SO ANGRY or UPSET that you wanted to PHYSICALLY HARM YOURSELF or SOMEONE ELSE?
 *
Required
Has the Client EVER been prescribed ANY of these MENTAL HEALTH medications? *
Required
Has the client EVER been prescribed ANY of these PHYSICAL HEALTH MEDICATIONS?
 *
Required
Does the Client have ANY OF THE FOLLOWING MEDICAL CONDITIONS? *
Required
Has the client BEEN HOSPITALIZED IN THE LAST 14 DAYS? *
Required
Does the Client have CHILDREN IN DCFS CUSTODY UNDER THE AGE OF 11? *
Required
Do you approve of receiving text communications to setup appointments?
Additional comments that ODYSSEY may want to consider in admitting this client :
A copy of your responses will be emailed to .
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