Date* MM slash DD slash YYYY Location*Please choose location nearest you.Newton Center - 8201 Hazelbrand Road, Covington, GA 30014Rockdale Center - 977A Taylor Street, Conyers, GA 30012Alianza (Spanish speaking location) - 6020 Dawson Blvd, Suite 1, Norcross, GA 30093Norcross Center - 5030 Georgia Belle Court, Suite 2036, Norcross, GA 30093Lawrenceville Center - 175 Gwinnett Drive, Lawrenceville, GA 30046 Name* First Last Email* Date of Birth* MM slash DD slash YYYY HiddenAgeHidden to keep data, but replaced with DOBAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Alternate PhoneEmergency Contact Name* Relationship* Emergency Contact Phone*Please READ **If you are having thoughts of harming yourself or others, STOP HERE and call 911 or the GA Crisis Line 1-800-715-4225**Are you currently a client at this Center or any View Point Health Center?* Yes No Do you have insurance?* Yes No If yes, what is name of insurance? NEW Clients: How did you hear about us? Friend Hospital GCAL Probation/Parole Parent Accountability Court Website If you have a family member or friend who works at View Point Health, please provide the staff member's name and relationship to you. If referred by GCAL, when was the referral made? MM slash DD slash YYYY Tell us why you are here today (check all that apply)* To begin outpatient mental health treatment To begin outpatient substance abuse treatment Recently released from jail/prison Open DFCS case To be assessed for crisis and/or inpatient treatment/hospitalization or detox For information only (stop here) Other If Other, please explain: If Hospital discharge (within last 2 weeks)Hospital Name Hospital Admit Date MM slash DD slash YYYY Hospital Discharge Date MM slash DD slash YYYY What problem(s) have you experienced in the last 3 days (check all that apply):* Select All Depression Problems in relationships Work/School Stress Legal Issues/Court-Mandated Anger/Aggression Family recommended Treatment Domestic Violence Thoughts of Killing Myself Paranoia Change in Sleep Patterns Anxiety Detox/Alcohol and Drug Use Thoughts of Killing Others Seeing/Hearing Things Others Do NOT Hear/See Other If Other, Please Explain: Do you own a weapon, have access to, or are you currently carrying a weapon? Yes No ***Please know that View Point Health no longer prescribes any Controlled Substances (ex: Xanax, Valium, Klonopin, Ativan or any ADHD medications for adults**Agree* Please Initial:Initial* PhoneThis field is for validation purposes and should be left unchanged.
