Self-Assessment Tool
Locations
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Pre-Screen

Safety Screen
MM slash DD slash YYYY
Start Time(Required)
:
Right now, are you having any mental health symptoms that feel like an emergency, such as hearing or seeing things others do not, very strong paranoia, severe confusion, or feeling out of touch with reality(Required)
Any recent thoughts of harming yourself or others(Required)
Any history of violence or aggression (including threats, assaults, weapons involvement, violent charges, or recent restraining orders)(Required)
History of suicide attempts(Required)
Special Considerations and Coordination Needs
Special medical or coordination needs (check all that apply)(Required)
Are you registered as a Tier Three sex offender(Required)
Dimension 1 Intoxication Withdrawal Addiction Medications
Is the client currently intoxicated(Required)
Currently in withdrawal or expected to enter withdrawal soon(Required)
History of severe withdrawal(Required)
Dimension 2 Biomedical Conditions
Any current or past medical conditions or concerns(Required)
Any mobility issues or use of assistive device(Required)
Do you currently take any prescription medications(Required)
Do you currently see any outpatient providers (PCP, mental health, MAT, pain management, specialty, or other)(Required)
Dimension 3 Psychiatric and Cognitive
Any current or past mental health diagnoses(Required)
Do you have difficulty reading or writing or understanding information in English (or communicating hearing speaking understanding)(Required)
History of psychiatric hospitalizations or substance abuse treatment(Required)
Dimension 4 Substance Use Related Risks
Able to participate fully in treatment now(Required)
Dimension 5 Recovery Environment
Do you have safe and/or stable housing(Required)
Transportation available to attend care(Required)
Legal Coordination
Currently involved with the legal system(Required)

Coordinator selects LOC below. Auto weighting removed by design. Use the box to briefly justify the placement.

1 to 3 sentences on key risks or needs that drive LOC choice and any timing or coordination notes.