Clinical Screening Questionnaire

Personal Informaiton

Are you a resident of South Carolina?(Required)
Name(Required)
Date of Birth(Required)
Today's Date(Required)
Phone(Required)

General Health

Do you have any ongoing physical or mental health conditions?
Physical Health Conditions:
If you answered "yes" above, please check any that apply or list others in the blank lines provided:
Mental Health Conditions:
Are you currently taking any prescribed or over the counter medications?

Substance Use History

In the past 12 months, how often have you used the following substances?
Alcohol
Cannabis (THC, edibles)
Cocaine/Crack
Heroin/Opioids
Prescription drugs (non-medical use)
Methamphetamine
Ecstasy/MDMA
Benzodiazepines (e.g. Xanax)
Kratom
Other

Impact & Risk

Have you ever felt you should cut down on your substance use?
Have others criticized your substance use or suggested you stop?
Do you use substances in the morning to feel better or steady your nerves?
Has substance use affected work, school, relationships, or housing?
Are you experiencing any of the following symptoms?
Have you received treatment/support for substance use in the past?
Date
Resolved
Date
Resolved
Date
Resolved
Date
Resolved
Check any that apply:

Mental Health Screening

In the past 2 weeks, how often have you experienced the following?
Feeling down/hopeless
Loss of interest in activities
Feeling anxious/nervous
Trouble relaxing
Sleep difficulties
Feeling worthless/guilty
Trouble concentrating
Thoughts of self-harm
Would you like to talk to a counselor about this?

Readiness to Change

How ready are you to change your substance use today?
Check one:
Your goal right now:

Medication History

List any past medications or treatments used for substance use or mental health. Indicate if they were helpful
Effective
Effective
Effective
Effective
Effective

Family & Genetic History

Check any that apply to your biological family:
Mental Health / Substance Use:
Medical Conditions:

Support System

Do you have a support system (friends, family, group)?
Are you working with any providers or support programs now?

Hospitalization History

List past or recent hospitalizations for medical, psychiatric, or substance-related reasons.
Date
Resolved
Date
Resolved
Date
Resolved
Date
Resolved
Date
Resolved
Have you ever been hospitalized?

Social Determinants of Health

Do you need assistance accessing medical care?
Do you have Healthcare Coverage?
Do you need assistance with transportation?
Do you need assistance with employment?
Do you need assistance with education?
Do you need assistance with housing (including utilities & internet)?