Apply for Services

Alternative Paths, Inc.

Pre-Admission Screening Form

Please either download the form and send it in or complete the form in the fields below:

PLEASE NOTE:  If you are currently suicidal or experiencing a psychiatric crisis, immediately contact Crisis Services at (330) 725-9195.

*First Name:

*Last Name:

Address:

City:

State: -- Select a State -- Alabama Alaska Alberta Arizona Arkansas British Columbia California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick New Hampshire New Jersey New Mexico New York Newfoundland North Carolina North Dakota North West Territories Nova Scotia Nunavut Ohio Oklahoma Ontario Oregon Pennsylvania Prince Edward Island Puerto Rico Quebec Rhode Island Saskatchewan South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Yukon Territory

Zip Code:

Phone:

Email:

Date of Birth:

Age:

Race:

Gender: -- Select a Gender -- Male Female

Marital Status:

Veteran: Yes
No

Service Connected: Yes
No

Medical Insurance: -- Select One -- None Medicaid Medicaid Part B Private

Income Source: -- Select One -- Employment SSI/SSDI Spouse/Parent Support Other

Guardian: Yes
No

Guardian Name/Relationship:

Phone Number:

Emergency Contact:

Relationship:

Address:

Phone Number:

May we leave a message at this #?: Yes
No

May we mail you at this address?: Yes
No

Requested Services: Psychiatrist
Counseling
Case Management
Groups

Referral Source: -- Select One -- Self Family/Friend Hospital Court/Probation Jail Other Agency/Provider

Agency/Organization Name:

Contact Person:

Phone Number:

Reason for transfer/request:

Signs/Symptoms (check all that apply): Anxiety/worry
Depression/sadness
Repeated habits/rituals
Excessive fearfulness
Excessive energy
Hear/see things that other don't
Intrusive thoughts
Impulsive
Angry outbursts
Suspicious of others
Mood swings
Change in eating pattern
Change in sleep pattern
Victim of physical, sexual or emotional abuse
History of suicide attempts
History of violence towards others

Please give additiona information on items checked:

Have you been hospitalized for psychiatric care?: Yes
No

If yes, please list when, where & why:

Your compliance with treatment was: -- Select One -- Very Consistent Somewhat Consistent Inconsistent

Have you ever abused, misused or had concerns with drug and/or alcohol use?

Drugs: Yes
No

Alcohol: Yes
No

Have you ever received drug and/or alcohol treatment (inpatient or outpatient)?

Answer: Yes
No

If yes, please list when and where:

Do you have any pending legal charges and/or are you currently on Probation or Parole?

Answer: Yes
No

If yes, please list which court:

Name/phone # of PO:

Do you have any past arrests/incarcerations/legal involvement?

Answer: Yes
No

If yes, please explain:

Please rate the following:

I care for my health, financial & household needs: -- Select One -- Strongly Agree Agree Neutral Disagree Strongly Disagree

My mental health symptoms prevent me from functioning at home/work.

Answer: -- Select One -- Strongly Agree Agree Neutral Disagree Strongly Disagree

*Security Key: