Inipi Screening Form

Screening and Referral Form

If you or someone you are referring would like to be considered for the Inipi Healing the Next Seven Generations program
please complete the form below and our intake specialist will be in contact with you soon! Please fill out completely in order to be processed for entry/added to wait list as quickly as possibly.

*Please make sure to click submit at the bottom of the screening form*

Screening and Referral Form

Name *

How did you hear about Medicine Wheel? *

Date of Birth *

Returning client? *

Yes No

Did you successfully complete the program, or what were the circumstances of you leaving?

Please Describe *

Are you in a relationship with or have a previous relationship with any current MWRS participant? *

Yes No

**We do not serve “couples” or those who are in intimate relationships. If your partner is a current participant here, you will remain on the waitlist until they have completed or are no longer receiving services here. If it is discovered that you do not disclose information about your partner being a participant, you will be discharged, and your partner will also be at risk of discharge.

Do you comply with our relationship protocol *

Yes No

** If accepted into the program, we will be calling you to arrange for your bed date. Please provide us with a phone number where we can contact you and/or leave a message. This should be a contact source that is checked at least daily. If we are unable to contact you to arrange for admittance, you will be moved to the bottom of the list. This screening is only valid for 30 days, those who are on the list but who have no contact for 30 days or more are removed from the list. You may complete another screening at any time in the future.

Phone Number *

can we text and leave messages/texts on this number? *

Yes No

Please provide all contacts name(s) and number(s) to be reached at *

Can we leave messages/texts at the above numbers? *

Yes No

Email *

Name of Insurance *

Substance(s) of choice? *

Route of Administration *

Substances used in the last 90 days? *

Date of last use *

History of withdrawl? *

Yes No Don't KNow

Have you ever gone to detox? *

Yes No

Mental Health History or Diagnosis? *

Yes No

Please Describe *

If yes, History of any prescribed Mental Health Medications and what they are prescribed for *

**MWRS only has the capacity to serve lower level co-occuring mental health needs due to staff and location constraints. Example: Trauma (PTSD), Anxiety, or Depression and a substance abuse issue. MWRS cannot meet the needs of individuals with higher level diagnosis such as Schizophrenia or Schizoaffective Disorder and we do not provide only mental health services in this program. The Inipi Healing the Next Seven Generations Program is primarily focused on addiction issues.

Are you currently participating in Medicated Assisted Treatment (MAT)? *

Yes No

If yes, which medication(s) are you prescribed? *

** Note: Due to our location and the process for methadone treatment, we are unable to serve those receiving methadone medication and services. Also, participants in our lodging program who utilized suboxone must get on to/or move to the injectable shot version of the medication. This is not negotiable.

Are you willing to move to the shot? *

Yes No

Have you had a Covid vaccine? *

Yes No

If no, are you willing to get one (required)? *

Yes No

Are you currently pregnant? *

Yes No

If yes, how far along are you? Have you had any prenatal care? *

Do you have chronic health conditions for which you are being treated or that is untreated? *

Yes No

Are you currently on any medication? *

Yes No

If yes, please list all prescribed medications *

** We do not provide 24/7 medication management, and you must be able to manage your own medications (MAT, mental health, and medical) independently and as prescribed while you are here.

Can you independently care for yourself (complete daily living tasks such as hygiene, meal preparation, cleaning of your living space, medication management, etc.)? *

Yes No

Do you have any children you want to bring with you to treatment? Do you have custody? Please list, Name and date of Birth for your children. *

**There is a limited number of beds available for participants with children accompanying a parent to treatment. There is also a maximum cap of two children per participant. Once the cap is met for those slots we will not be able to accept any new participants. Participants can choose to come without their child/children and be placed on the wait list to join the parent when slots open. You will also be asked to complete a screening form for your children when our outreach specialists contact you.

Are you Native American? *

Yes No

If yes, are you enrolled? *

Yes No

What tribe(s) are you enrolled in? *

If not enrolled, are you eligible to enroll? *

Yes No

Do you currently have an open CPS/DHS case? *

Yes No

Are you on probation/parole? Pre-Trial? Are you Federally Involved? DUII? Tribal Court? *

Yes No

If yes please describe *

** We want to support you in being successful in completing all legal requirements. If you have current court proceedings, arrangements will need to be made to attend by phone/zoom, etc. while you are in treatment if your court is outside of our catchment area (200 miles radius from this center, or on Warm Springs, Umatilla, Yakama, or Nez Perce Tribal lands)

Have you been convicted of a sex offense or arson crime? *

Yes No

** We will assist when possible with transport to treatment.
** We only provide transportation home in the case of successful treatment graduation. If you leave or are terminated from the program, we do not offer any transportation assistance.

Will you be needing transportation assistance? *

Yes No Maybe

Do you have a valid REAL ID or Tribal ID?? *

Yes No

What is the nearest transport location to you? *

Do you currently have food stamps, TANF, or income? *

Are you allergic to Horses, Chickens, Dogs, or any other animal? Yes or No? If yes please explain which one(s) *

**We are non-tolerant of violence, bullying and discrimination. Please leave your past conflicts behind when you come here as you may see someone here that you have previously had issues with. This is not the place to continue those conflicts.**

Submit