Initial ScreeningScreening intake formPlease fill out the form, and submit it to EPRA and we will follow up as soon as possible. Name * First Name Last Name Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone (###) ### #### BACKGROUND INFORMATION Income Information How are you presently supporting yourself? PA (Public Assistance) SSI (Social Security Insurance) SSDI ( Social Security Disability Insurance) UI (Unemployment Insurance) Family/Friends Other Supplemental Income Last Position Held Highest Education High School Diploma GED AAS Bachelors Masters Doctorate Do you have a current Resume? Yes No I need help with a resume Are you abstinent (from alcohol and substances)? Yes No, but Im trying If Yes, how long have you been clean? Are you currently in treatment Yes No Recently completed TREATMENT INFORMATION Name of Counselor First Name Last Name Phone (###) ### #### Email Line Have you ever applied to ACCES Yes No If Yes, When did you apply? MM DD YYYY Which Borough did you apply in? Manhattan Bronx Brooklyn Queens Staten Island Did you receive any other Services from ACCES? MEDICAL HISTORY HIPPA LAWS APPLY Do you have insurance Yes No I don't know If Yes, What kind of Insurance do you have? Medicaid Medicare Disability Private Insurance Are you being treated for psychical/medical conditions? Yes No If Yes, List your Emotional or Psychiatric conditions i.e. Anxiety, Depression, Bi-Polar Disorder, PTSD, Schizophrenia, Mental disorders etc REFERALS Reference First Name Last Name Thank you!
