Screening | Gateway Recovery

Gateway Recovery Village Intake Screening

Please answer the following questions about the person seeking help

I am a:

Person seeking help?

Family member of someone seeking help?

Friend of someone seeking help?

Add your text

First name

Last name

Phone Number

Email (if any)

Birthday

Month

Day

Year

Substance Use History

Multi choice

How long have you been using these substances? (Please select one)

How frequently do you use these substances? (Please select one)

When did you last use? (Please select one)

Have you ever been treatment for substance use before?

Yes

No

If yes, please list facility name, treatment dates, type of treatment.

Are you currently in any form of treatment or counseling?

Yes

No

Do you currently have Private Insurance or Medicaid?

Yes

No

What is the name of the insurance that you currently have that is active?

Information Submitted is Encrypted, HIPAA & 42 CFR Protected HIM