Hope Grows In Our Common Ground
Online Screening - Assessment Form
NOTE: This form resides on a completely secure page and the information you enter will be sent to OCG via encrypted email and will remain entirely confidential.
First Name:
Last Initial:
Relationship:
Age:
DOB:
Please select your preferred method of contact:
Contact Telephone:
Contact Email:
Best Time:
Morning
Afternoon
Evening
Anytime
Please state your alcohol or drug (AOD) use history:
Have you participated in AOD treatment previously:
Yes
No
If yes, which modality:
Residential
Day Treatment
Outpatient
For How Long:
30 days
60 days
90 days
6 months or more
Are you taking any prescribed psychotropic medication?
Yes
No
If yes, please explain:
Are you currently involved in the criminal justice system?
Yes
No
If yes, please explain:
A representative from our intake and admissions department will contact you shortly to schedule a confidential interview.
Privacy Policy
Any information submitted on this online screening & assessment is protected by federal privacy and confidentiality regulations (42cfr & HIPAA). This information cannot and will not be shared with anyone outside of OCG without your expressed written consent.
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