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Set Free Assessment Form - Mat-Su
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Client Profile
Name
*
First
Last
Client Gender
*
Male
Female
If female, maiden name required.
*
Mailing Address
*
Street Address
City
Alabama
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Armed Forces Americas
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State
ZIP Code
Email
Enter Email
Confirm Email
Main Contact Phone
*
Other Phone
Date of Birth
*
MM
DD
YYYY
Social Security Number
SACC Client Id Number (if known)
Demographics
Races(s): Check all that apply
*
American Indian
Asian
Caucasian
Native Hawaiian
Pacific Islander
Alaska Native
Aleut
Athabascan
Haida
Tlingit
Tsimshian
Yupik
Other Alaska Native
Other
Unknown
Ethnicity: Check One
*
Not Spanish / Hispanic / Latino
Chicano
Cuban
Hispanic
Mexican American
Puerto Rican
Spanish / Hispanic / Latino
Unknown
English Fluency: Check One
*
Excellent
Good
Moderate
Poor
Not at all
No response
Education: Check one
*
If K-11, state how many years in the box below.
GED
High School Diploma
Vocational Training
Special Ed Classes
Bachelors Degree
Graduate Work (no degree)
Masters Degree
Doctorate Degree
Post Secondary 1 yr
Post Secondary 2 yrs
Post Secondary 3 yrs
Post Secondary 4+ yrs (no degree)
Unknown
Highest Level Education Completed
*
Veteran Status: Check one
*
Never in Military
Reserves / National Guard - Combat
Reserves - No Combat
Military Dependant
Active Duty - Combat
Active Duty - No Combat
Retired From Military
Verteran Other Eras
Vietnam Vet - Combat
Vietnam Vet - No Combat
Unknown
Special Needs: Check all that apply
*
None
No Response
Dev Disabled
Major Difficulty in Ambulating
Moderate to Severe Medical Problems
Severe Hearing Loss or Deaf
Traumatic Brain Injury
Visual Impairment or Blind
Unknown
Intake Information
Initial Contact: Check one
*
Phone
Drop In (Orientation)
Hospital / On Call Intervention
Community Service Patrol
By Appointment
Other
City / Village: Check one
*
Anchorage
Eagle River
Wasilla
Palmer
Other location outside of Anchorage bowl area (specify below)
Source of Referral: Check one
*
ASAP
Federal Probation
Office of Children's Services
Department of Corrections / Jail
Correctional Agency (Probation of Parole)
Court - Civil Proceedings
Court - Criminal Proceedings
Individual / Self Referral
Crisis / Respite Care
Alaska Native Hospital
Detox or Residential Program
API
Assisted Living Facility
Attourney
Developmental Disabilities Residential Program
Developmental Disabilities Program
Drug Program, Employer (EAP)
Halfway House
Nursing Home
Other Mental Health (not including psychiatrist)
Other
Only Required if Female: Pregnant?
Yes
No
If Yes: Due Date
Date Format: MM slash DD slash YYYY
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
*
Theraputic Courts
Women With Children
Aquired Brain Disorders
Adult - Organic Disorder without SED
Adult - Severe & Persistent Mental Illness
Adult - Severe Emotional Disturbance
Fetal Alcohol Syndrome
HIV
Methadone
Persistant & Disabling Personality Disorder
Psychiatric Emergency Services
Traumatic Brain Injury
None
Consent
*
By signing and submitting this form, I am giving consent to Set Free Alaska to enter my identifying information on Alaska’s Automated Information Management System (AKAIMS). Furthermore, I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the agencies identified above may not condition my treatment on whether I sign a consent form, but that in certain circumstances I may be denied treatment if I do not sign a consent form.
Signature
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Comments
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Home
About
▲
Meet The Staff
SFA Board of Directors
Founders Video
Strategic Plan
Annual Report
Press & Support
Services
▲
Outpatient Services – Mat-Su
Outpatient Services – Homer
Children / Adolescent Services
Women’s Residential Treatment
Men’s Residential Treatment
Assessment
Costs
Notice of Privacy Practices
Donations
▲
Christmas 2020
Testimonies
Employment
Contact
▲
Mat-Su Office 907-373-4732
Homer Office 907-235-4732
Connect
Connect
Set Free Alaska
Phone 907-373-4732
Fax 907-746-4749