Give Your Support

Screening Date *

Medical Information

Seen by a doctor in the last 30 days?YesNo

Seen by a doctor – Where?

Primary Care ProviderYesNo

Provider Name

Phone

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

MaineCareYesNo

MaineCare ID

Receiving substance use services?YesNo

Receiving substance use services – Where?

Medication & Treatment

Prescribed MATYesNo

Prescribing Provider

Phone Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code

Current Medications

Allergies

Legal History

Have you ever been investigated, arrested, or convicted of violent crimes, sexual crimes, or arson-related crimes?YesNo

If yes, explain (include dates)

On probation or drug court?YesNo

Office / Officer Name

Office / Officer Phone Number

Mental Health & Safety

Mental Health Diagnosis

Have you experienced physical or emotional trauma?YesNo

Trauma – When?

Trauma – Explanation [ If you want to]

Medical Conditions

Currently suicidal or homicidal?YesNo

Suicidal or homicidal – Ever?YesNo

Suicidal or homicidal – Last date

Suicidal or homicidal – Explain

Substance Use History

Substance(s) of Choice

Method(s) of Use

Date of last use

Have you Overdosed?YesNo

Date Overdosed

Consequences of Use

Prior Substance Use Treatment (Facility/Year)

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Phone Number

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal code