OCG Works - Our Common Ground

Online Screening - Assessment Form

NOTE: This form resides on a completely secure page and the information you enter will be sent to OCG via this ssl form and will remain entirely confidential.

First Name:

Last Initial:

Relationship:

Age:

DOB:

Please select your preferred method of contact:

Contact Telephone:

Contact Email:

Best Time:

Morning

Afternoon

Evening

Anytime

Please state your alcohol or drug (AOD) use history:

Have you participated in AOD treatment previously:

Yes

If yes, which modality:

Residential

Day Treatment

Outpatient

For How Long:

30 days

60 days

90 days

6 months or more

Are you taking any prescribed psychotropic medication?

Yes

If yes, please explain:

Are you currently involved in the criminal justice system?

Yes

If yes, please explain:

A representative from our intake and admissions department will contact you shortly to schedule a confidential interview.

Any information submitted on this online screening & assessment is protected by federal privacy and confidentiality regulations (42cfr & HIPAA). This information cannot and will not be shared with anyone outside of OCG without your expressed written consent.