Modern Warrior Screening Form

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Modern Warrior Screening Form

Screening and Referral Form

If you or someone you are referring would like to be considered for the Modern Warrior program
please complete the form below and our intake specialist will be in contact with you soon!

* Indicates required field

Full Name *

Date of Screening *

Date of birth *

Returning client *

Yes No

Phone Number *

Can we text or leave a message at this number? *

Yes No

Email *

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

Address *

Line 1

Line 2

City

State

Zip Code

Country

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

Living situation *

Home/Apartment Homeless Family/Friends Incarcerated Treatment/Detox Other

Are you Native American? *

Yes No

If yes, are you enrolled? *

Yes No

If yes what tribe are you enrolled with? *

What is your current health insurance? *

OHP Uninsured Other

Have you had a Covid vaccine? *

Yes No

If no are you willing to get one *

Yes No

Date of last use *

Substances of choice *

Any current withdrawl symptoms *

Are you being referred by a court, P.O., or other program? *

Do you have any unresolved DUIIs? *

Yes No

Do you have any mental health diagnosis, if so what are they? *

Are you currently on any medications, including for mental health? *

Yes No

If yes, what medications are you taking? *

Name and DOB for child(ren) that are currently in your custody, or are in CPS/DHS custody for which you are trying to get back into your custody *

What are your plans for the care of your children while you are in treatment? *

Are you currently court-involved? (CPS/DHS, open charges, pending cases, probation etc.) *

Yes No

Are you Federally involved? *

Yes No

Do you have any arson crimes? *

Yes No

Are you a registered sex offender? *

Yes No

How did you hear about Medicine Wheel? *

Submit

Home
Services
Member Portal
Contact
Employment
MWRS Traditions

Modern Warrior Screening Form

Screening and Referral Form

© Medicine Wheel Recovery Services, Inc. 2023