Secure Site Maple Street Counseling 220 North 4th Street Rogers AR 72756-3712 479-685-8382 Intake 1. How did you hear about us? 2. What type of therapy are you seeking? Individual Couples Family Hybrid 3. What brings you in? 4. What would your partner say? 5. Length of these relationship: 6. Can you tell me a little bit about yourself and your family/culture/upbringing? 7. Can you tell me a little bit about what intimate relationships look like for you? 8. Do you have any dependents? 9. Therapy before: 10. Psychiatry before: 11. Medications (type & dosage frequency): 12. Alcohol and Drug Use (type & dosage frequency): Select 0 - 4 drinks a week 5 - 8 drinks a week 9 - 15 drinks a week 15+ drinks a week       Describe use: 13. Marijuana/Cannabis products: Yes No    Select 0 - 4 times a week 5 - 8 times a week 9 - 15 times a week 15+ times a week       Do you have a medical marijuana card? Yes No       Describe use: 14. Recreational drugs: Yes No       Describe use: 15. Suicidality:       Ideation: Yes No       Describe, including whether ideation has occurred in the last 2 weeks:       Planning: Yes No       Describe, including whether planning has occurred in the last 2 weeks:       Attempts: Yes No       Describe including year(s) of occurrence and outcome:       Means: Yes No 16. Self Harming Behaviours: Yes No       Describe, including most recent incident: 17. Violence Towards Others: Yes No       Describe, including most recent incident: 18. Physical/Emotional/Sexual abuse in the past: Yes No       Describe: 19. Experience of life being threatened by person, accident, or natural disaster: Yes No 20. Hospitalizations for Psychiatric Reasons: Yes No       Describe, including year of occurrence, diagnosis (if possible) and resulting treatment: 21. Actions taken concerning above risks: 22. Religious Affiliation/Denomination: 23. Occupation: 24. Preferred Location: 25. School: (grade/year, graduation date & current GPA): 26. City Year Employee: (site name, site grade level, & program manager): 27. Availability: 28. Clinician assigned: 29. Initial Appointment: 30. Client Informed of Fee: Insurance and/or Sliding scale amount: 31. Client Informed of 2 business day cancellation policy: Yes No 32. Who did the intake: Secure Site Maple Street Counseling 220 North 4th Street Rogers AR 72756-3712 479-685-8382 Intake 1. Occupation: Youth worker: No describe Yes describe 2. If City Year Employee: (site name, site grade level, & program manager): 3. How did you hear about us? 4. What type of therapy are you seeking? Individual Couples Family Hybrid Group 5. What brings you in? 6. Client stated strengths 7. Can you tell me a little bit about yourself and your family/culture/upbringing? 8. Tell me a little bit about your community & social supports 9. Do you have any dependents? 10. Therapy before: 11. Psychiatry before: 12. Medications (type & dosage frequency): 13. Alcohol and Drug Use (type & dosage frequency): Select 0 - 4 drinks a week 5 - 8 drinks a week 9 - 15 drinks a week 15+ drinks a week       Describe use: 14. Marijuana/Cannabis products: Yes No    Select 0 - 4 times a week 5 - 8 times a week 9 - 15 times a week 15+ times a week       Do you have a medical marijuana card? Yes No       Describe use: 15. Recreational drugs: Yes No       Describe use: 16. Suicidality:       Ideation: Yes No       Describe, including whether ideation has occurred in the last 2 weeks:       Planning: Yes No       Describe, including whether planning has occurred in the last 2 weeks:       Attempts: Yes No       Describe including year(s) of occurrence and outcome:       Means: Yes No       Access to any weapons, if so type: 17. Self Harming Behaviours: Yes No       Describe, including most recent incident: 18. Violence Towards Others: Yes No       Describe, including most recent incident: 19. Physical/Emotional/Sexual abuse in the past: Yes No       Describe: 20. Experience of life being threatened by: Person Accident Natural Disaster 21. Hospitalizations for Psychiatric Reasons: Yes No       Describe, including year of occurrence, diagnosis (if possible) and resulting treatment: 22. Actions taken concerning above risks: 23. Religious Affiliation/Denomination: 24. Preferred Location: 25. School: (grade/year, graduation date & current GPA): 26. Availability: 27.Insurance and/or Sliding scale amount: Everything below is for Office Staff Only to Complete 28. Clinician assigned: 29. Initial Appointment: 30. Client Informed of Fee: 31. Client Informed of 2 business day cancellation policy: Yes No 32. Who did the intake: 32. Youth worker: Yes No 33. Describe if not occupation (under occupation) Secure Site Maple Street Counseling 220 North 4th Street Rogers AR 72756-3712 479-685-8382 Intake 1. How did you hear about us? 2. What type of therapy are you seeking? Individual Couples Family Hybrid 3. What brings you in? 4. Suicidality:       Ideation: Yes No       Describe, including whether ideation has occurred in the last 2 weeks:       Planning: Yes No       Describe, including whether planning has occurred in the last 2 weeks:       Attempts: Yes No       Describe including year(s) of occurrence and outcome:       Means: Yes No 5. Violence Towards Others: Yes No       Describe, including most recent incident: 6. Hospitalizations for Psychiatric Reasons: Yes No       Describe, including year of occurrence, diagnosis (if possible) and resulting treatment: 7. Client Informed of Fee: Insurance and/or Sliding scale amount: 8.Client Notes a: b: Secure Site Maple Street Counseling 220 North 4th Street Rogers AR 72756-3712 479-685-8382 Driver License Front Ins Card Front Driver License Back Ins Card Back Secure Site Maple Street Counseling 220 North 4th Street Rogers AR 72756-3712 479-685-8382 Intake Intake Question Referral Source Select Maryhaven Talbot Hall Woodhaven Recovery Works Recovery Village Outreach and Crisis Federal Probation Hospital Self Another Client First Step Minerva Park Sun Behavioral Columbus/Dublin Springs Are you currently on active duty? Yes No Military Branch Select Armed Forces Reserves National Guard Highest Level of Education Select 8th 9th 10th 11th 12th GED Diploma Some College Some Tech School 2-year degree 4-year degree some post graduate school Masters Degree Employment status Select employed full time 35+ hours per week employed part time looking for work disabled unemployed volunteer work retired not looking for work refused don't know other Are you currently enrolled in school or job training program? Select not enrolled enrolled part time enrolled full time other Are you currently enrolled in school or job training program? Select not enrolled full time enrolled part time other allow a space to specify Are you currently using? Yes No Routine of administration types: Select oral nasal smoking non-iv injection During the past 30 days, how many days have you used any of the following: Cocaine/crack Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Marijuana/Hashish Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Heroine Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Morphine Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Dilaudid Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Demerol Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Fentanyl Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Percocet Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Darvon Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Codeine Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Tylenol 2, 3, 4 Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 OxyContin/Oxycodone Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Non-prescription methadone Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Hallucinogens/psychedelics, PCP, LSD, Mushrooms, or Mescaline Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Methamphetamine or other amphetamines Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 During the past 30 days, how many days have you used any of the following: Benzodiazepines: diazepam, alprazolam, Triazolam, and etizolam Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Barbiturates: Metharbital and pentobarbital sodium Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Non-prescription GHB Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Ketamine Select 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Other tranquilizers, downers sedatives, or hypnotic Inhalants Other illegal drugs Drug of Choice-Diagnosis Select F10.10 Alcohol Use Disorder-Mild F10.20 Alcohol Use Disorder-Mod F10.20 Alcohol Use Disorder-Severe F11.10 Opioid Use Disorder Mild F11.20 Opioid Use Disorder-Mod F11.20 Opioid Use Disorder-Severe F12.10 Cannabis Use Disorder-Mild F12.20 Cannabis Use Disorder-Mod F12.20 Cannabis Use Disorder-Severe F13.10 Sedative Use Disorder-Mild F13.20 Sedative Use Disorder-Mod F13.20 Sedative Use Disorder-Severe F14.10 Stimulant Use Disorder-Mild F14.20 Stimulant Use Disorder-Mod F14.20 Stimulant Use Disorder-Severe F15.10 Amphetamine Use Disorder-Mild F15.20 Amphetamine Use Disorder-Mod F15.20 Amphetamine Use Disorder-Severe F16.10 Hallucinogen Use Disorder-Mild F16.20 Hallucinogen Use Disorder-Mod F16.20 Hallucinogen Use Disorder-Severe Behavioral Health Children's Services Referral Yes No Select Adams County Allen County Ashland County Ashtabula County Athens County Auglaize County Belmont County Brown County Butler County Carroll County Champaign County Clark County Clermont County Clinton County Columbiana County Coshocton County Crawford County Cuyahoga County Darke County Defiance County Delaware County Erie County Fairfield County Fayette County Franklin County Fulton County Gallia County Geauga County Greene County Guernsey County Hamilton County Hancock County Hardin County Harrison County Henry County Highland County Hocking County Holmes County Huron County Jackson County Jefferson County Knox County Lake County Lawrence County Licking County Logan County Lorain County Lucas County Madison County Mahoning County Marion County Medina County Meigs County Mercer County Miami County Monroe County Montgomery County Morgan County Morrow County Muskingum County Noble County Ottawa County Paulding County Perry County Pickaway County Pike County Portage County Preble County Putnam County Richland County Ross County Sandusky County Scioto County Seneca County Shelby County Stark County Summit County Trumbull County Tuscarawas County Union County Van Wert County Vinton County Warren County Washington County Wayne County Williams County Wood County Wyandot County If Children's Services referral, do you have an active Children's Services case? Yes No # of children that you have # of children that you have Crime Justus status Select On Probation On Parole Has pending Charges Warrants Ankle Monitor Device Fines or Fees Probation Yes No Parole Yes No PROB 45 Yes No Human Trafficking Is there a history of Sexual Abuse? Select sexual assault child sexual abuse incest intimate partner sexual violence sexual assault of men and boys drug facilitate sexual assault Program Placement (Level of Care) Select 2.5 Partial Hospitalization 2.1 Intensive Outpatient Program 1.0 Outpatient Sober Housing Needed Yes No Sober Housing Provided Yes No     Medical Intake Questions If female, are you pregnant? Yes No Medicated Assisted Treatment (MAT) Hypertension Diabetes Select type 1 type 2 STI's UTI's Cellulitis COPD Asthma Blood dyscrasia City State Zip code County Is there a history of drug use? Yes No In the past 30 days, where have you been living most of the time? Select shelter street/outdoors institution housed if housed - own/rent someone else's apartment room or hotel dormitory/college residence halfway house residential treatment refused to answer don't know other Are you currently employed? Select employed full time 35+ hours per week employed part time unemployed looking for work unemployed disabled unemployed volunteer work unemployed retired unemployed not looking for work other (allow space for information) refused don't know Secure Site Notes Secure Site Add Card Details Card Holder Name: Card Type: Visa MasterCard Discover American Express JCB Diners Unknown Card Number: Expiration Date: 01 02 03 04 05 06 07 08 09 10 11 12 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033 2034 2035 2036 2037 2038 2039 2040 2041 2042 2043 Address: Zip: A valid debit or credit card number is required to complete registration. All federally required safety measures are in place to protect your financial and private health information. 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