October Road Inc., Client Screening Form Client referral: Walk-in      Phoned      Website Date of Contact:  Referring agency: Client Name: Phone: Address: City:  State: Zip Code: Social Security#: Date of Birth: Age: Gender: Male      Female Insurance: Insurance phone#: Medicaid#: Medicare#: IPRS: Current Mental Health Care Provider: Reason for call: Substance Abuse/Dependency: Danger to self or others: Yes     No History of suicidal ideations or homicidal ideations: Psychiatric Hospitalizations: Yes, if checked How Many: When: Where: Current Medications: Mental Health   Substance Abuse   DWI   DSS   Drug Court   TASC   SAIOP Marital Status: Single   Married   Separated   Divorced   Widowed   Domestic Partners Living Arrangement: Adult Care Home   Homeless/shelter   Private Residence   Other: Transportation: Independent driver   No Drivers License   Medicaid Transport   Bus Needs assistance with transportation ::