Center Based Screener For Adults

Center Based Screener: Blooming Minds (Adult)

If you are in a state of crisis or need immediate help for any reason, please pause filling out this form and call 911. If you feel that you are a danger to yourself, please contact the National Suicide Prevention lifeline at 1-800-273-8255

Center Based Screener

Adult MUST be over 18 years of age and does NOT have a legal guardian.(Required)

PREREQUISITE FOR PROGRAM ADMISSION: Adult MUST meet the following for the group intervention to be impactful.

Click yes or no to questions below.
Are you able to refrain from physical aggression, vocal outbursts, and property destruction when experiencing strong emotions or difference in opinion from others?(Required)
Would you be able to participate in a classroom style workshop for a period of 60 minutes?(Required)
Are you able to communicate wants and needs to peer(s) and group facilitators in an appropriate manner?(Required)
Have you struggled with substance abuse in the last 30 days?(Required)
What are you currently struggling with? (Select all that apply)(Required)
In the last 30 days what were your top 3 stressors?(Required)
Have you ever received any type of therapy?
Have you been hospitalized for any reason in the last 30 days?

Contact Information

Name(Required)
MM slash DD slash YYYY
What is your preferred method of contact?(Required)

Disclaimer

This is not a guarantee of services. This form is utilized as an initial screening process for staff purposes only. If it is determined that you may be a potential fit for the program, a member of our staff will reach out to you.