Assessment Application & Payment Form - Homer - Set Free Alaska

Intake Information

Initial Contact: Check one*

City / Village: Check one*

Source of Referral: Check one*

Only Required if Female: Pregnant?

Yes
No

If Yes: Due Date

Injection Drug User (within the last 12 months)*

Yes
No
Unknown

Primary Presenting Problem:*

Alcohol & Drugs
Alcohol
Drugs

Secondary: (Specify From List Below. If none put N/A)*

Tertiary: (Specify From List Below. If none put N/A)*

(Alcohol & Drugs Alcohol Only; Drugs Only; Suicide attempt/threat; Child abuse victim; Sexual abuse victim; Domestic violence victim; Eating disorder; Thought disorder; Depression; Social/interpersonal (not family); Coping with daily roles/activities; Marital; Family (non marital); Medical/somatic; Psychological/emotional; Financial; Poverty; Child abuse perpetrator; Sexual abuse perpetrator; DV perpetrator; None; Other; Unknown)

Presenting Problem(s) in clients own words: Why is the client seeking services?*

Special Initiative: Check all that apply*

Your Almost Finished!

Submit this form and you will be directed to a payment page to complete the process.

Select Payment Type*

Private Insurance or Self Pay
Medicaid

$80 Payment to Schedule Assessment

Price: $80.00 Quantity:

Total

$0.00

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Comments

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Set Free Assessment Form - Homer

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Client Profile

Demographics

Intake Information

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Help Center

Set Free Alaska

Phone 907-373-4732

Fax 907-746-4749