Alliance Wellness Center

Alliance Wellness Center

245G Initial Screening Form

This is an initial screening form — not a full clinical assessment. The information you share helps our team understand your needs and determine the most appropriate next step.

This form is not for emergencies. If you or someone else is in immediate danger, experiencing a medical emergency, or having thoughts of suicide or self-harm, please call 911 or go to your nearest emergency room immediately. You may also call or text the 988 Suicide & Crisis Lifeline by dialing 988.

1

Client Information

2

Substance Use & Treatment History

3

Mental & Physical Health

If you are in immediate danger or experiencing a crisis, please call 911 or the 988 Suicide & Crisis Lifeline (call or text 988) right away. Do not wait for a response to this form.

4

Living & Support

5

Services of Interest

Staff Screening Summary

Staff use only

Privacy & Confidentiality: The information you provide on this form is confidential and will only be used by Alliance Wellness Center staff to determine appropriate services and support. Your information will not be shared publicly or with unauthorized third parties. All submissions are handled in accordance with applicable state and federal privacy laws, including 42 CFR Part 2 and HIPAA.