Inipi Screening Form

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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!

Screening and Referral Form

* Indicates required field

Name *

Date of screening being submitted *

Returning client? *

Yes No

Date of Birth *

Phone Number *

can we text and leave messages on this number? *

Yes No

Email *

contact name and number we can communicate if you do not have a phone *

Name of Insurance *

Substances used in the last 90 days? *

What substance(s) do you use first if given a choice

Date of last use *

Substance(s) of choice? *

What substances do you use first if given the choice

Route of Administration *

How do you use your substance? Smoke, drink, snort, IV, etc.

History of withdrawl? *

Yes No Don't KNow

Have you ever gone to detox? *

Yes No

Mental Health History? *

Yes No

Have you ever received mental health care?

If yes, Diagnosis and History of any prescribed Medications *

Are you currently pregnant? *

Yes No

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

Are you currently on any medication? *

Yes No

If yes, please list all prescribed medications *

Do you have any children? Do you have custody? Are you wanting your children to come with you? Please list, Name and Date of Birth for children(Maximum of 2 children can come with parent that meet program guidelines) *

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

Are your children enrolled? *

Yes No No children

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

Yes No

Are you on probation/parole? Are you Federally Involved? DUII? *

Yes No

If yes please describe *

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

Yes No

Will you be needing transportation assistance? *

Yes No Maybe

Do you have ID? *

Yes No

Do you currently have food stamps, TANF, etc.? *

Living situation *

Home/apartment Homeless Family/Friends Shelter Incarcerated Treatment/Detox Other

Current Address (If housed)/Location if unhoused *

Line 1

Line 2

City

State

Zip Code

Country

If you do not have a street address, please type no address in line 1 and complete the city, state and zip code for your current location.

Have you had a Covid vaccine? *

Yes No

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

Yes No

How did you hear about Medicine Wheel? *

Submit