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Clinical Screening Questionnaire
Personal Informaiton
Are you a resident of South Carolina?
(Required)
Yes
No
Name
(Required)
First
Middle
Last
Date of Birth
(Required)
Phone
(Required)
Country
Phone Number
Email
(Required)
Pronouns
General Health
Do you have any ongoing physical or mental health conditions?
Yes
No
Physical Health Conditions:
If you answered "yes" above, please check any that apply or list others in the blank lines provided:
Diabetes
High Blood Pressure
Heart Disease
Chronic Pain
Liver Disease
Asthma or other respiratory issues
Neurological condition (e.g., seizures, migraines):
Other
Mental Health Conditions:
Depression
Anxiety
Bipolar Disorder
PTSD
Schizophrenia or psychotic disorders
ADHD/ADD
Other
Other:
Are you currently taking any prescribed or over the counter medications?
Yes
No
If yes, please list them:
Who prescribes your medications?
Substance Use History
In the past 12 months, how often have you used the following substances?
Alcohol
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Cannabis (THC, edibles)
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Cocaine/Crack
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Heroin/Opioids
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Prescription drugs (non-medical use)
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Methamphetamine
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Ecstasy/MDMA
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Benzodiazepines (e.g. Xanax)
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Kratom
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Other
Other
Never
Once or Twice
Monthly
Weekly
Daily/Almost Daily
Is there anything that bothers you or worries you about these substances?
Impact & Risk
Have you ever felt you should cut down on your substance use?
Yes
No
Have others criticized your substance use or suggested you stop?
Yes
No
Do you use substances in the morning to feel better or steady your nerves?
Yes
No
Has substance use affected work, school, relationships, or housing?
Yes
No
If yes, please explain:
Are you experiencing any of the following symptoms?
Sweating or Tachycardia
Depressed/Dysphoric Mood
Diarrhea
Difficulty Concentrating
Fatigue
Fever or Chills
Flu-Like Symptoms
Hallucinations
Increased/Decreased Appetite
Irritability, Anger, or Aggression
Muscle Aches/Stomach Cramps
Nervousness or Anxiety
Psychomotor agitation or retardation
Restlessness
Runny Nose
Seizures
Shakiness/Tremors
Insomnia or Disturbing Dreams
None
Treatment Locations
Have you received treatment/support for substance use in the past?
Yes
No
Date
Reason
Resolved
Yes
No
Notes
Date
Reason
Resolved
Yes
No
Notes
Date
Reason
Resolved
Yes
No
Notes
Date
Reason
Resolved
Yes
No
Notes
Check any that apply:
Blackouts
Overdose
Arrests
Unsafe sex or needles
Injuries
None of the above
Mental Health Screening
In the past 2 weeks, how often have you experienced the following?
Feeling down/hopeless
Not at all
Several Days
More Than Half
Nearly Every Day
Loss of interest in activities
Not at all
Several Days
More Than Half
Nearly Every Day
Feeling anxious/nervous
Not at all
Several Days
More Than Half
Nearly Every Day
Trouble relaxing
Not at all
Several Days
More Than Half
Nearly Every Day
Sleep difficulties
Not at all
Several Days
More Than Half
Nearly Every Day
Trouble concentrating
Not at all
Several Days
More Than Half
Nearly Every Day
Thoughts of self-harm
Not at all
Several Days
More Than Half
Nearly Every Day
Would you like to talk to a counselor about this?
Yes
No
Not Sure
Readiness to Change
How ready are you to change your substance use today?
Check one:
Not thinking about change
Thinking about change
Preparing for change
Taking action now
Maintaining changes for 6 months +
Your goal right now:
Get information
Reduce Use
Quit entirely
Not Sure Yet
Medication History
List any past medications or treatments used for substance use or mental health. Indicate if they were helpful
Medication/Treatment
Reason
Effective
Yes
No
Notes
Medication/Treatment
Reason
Effective
Yes
No
Notes
Medication/Treatment
Reason
Effective
Yes
No
Notes
Medication/Treatment
Reason
Effective
Yes
No
Notes
Medication/Treatment
Reason
Effective
Yes
No
Notes
Family & Genetic History
Check any that apply to your biological family:
Mental Health / Substance Use:
Alcohol use disorder
Drug use disorder
Depression
Anxiety
Bipolar disorder
Schizophrenia
Suicide/self-harm
No known family history
Other
Other
Medical Conditions:
Diabetes
High blood pressure
Heart disease
Obesity
Liver disease
Seizures
Chronic pain
Cancer
Dementia/neurological issues
Support System
Do you have a support system (friends, family, group)?
Yes
No
Not Sure
Are you working with any providers or support programs now?
Yes
No
Not Sure
If yes, list:
Hospitalization History
List past or recent hospitalizations for medical, psychiatric, or substance-related reasons.
Date
Reason
Resolved
Yes
No
Notes
Date
Reason
Resolved
Yes
No
Notes
Date
Reason
Resolved
Yes
No
Notes
Date
Reason
Resolved
Yes
No
Notes
Date
Reason
Resolved
Yes
No
Notes
Have you ever been hospitalized?
Yes
No
Social Determinants of Health
Do you need assistance accessing medical care?
Yes
No
Not Sure
Do you have Healthcare Coverage?
Yes
No
Not Sure
If yes, which provider?
Do you need assistance with transportation?
Yes
No
Not Sure
Do you need assistance with employment?
Yes
No
Not Sure
Do you need assistance with education?
Yes
No
Not Sure
Do you need assistance with housing (including utilities & internet)?
Yes
No
Not Sure
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Alumni
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Paying for Counseling
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Donate
Events
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Community Involvement
Resources
About
Our Team
Results
Explore Employment Opportunities
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