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Graceland Psychiatric & Neuromodulation Center

Dual Diagnosis IOP / PHP Intake Screening

2411 Northeast Interstate Loop 410, Suite 114 · San Antonio, TX 78217-6644

This screening helps us determine the right level of care and prepare for your admission. It takes about 20–30 minutes. Answer what you can — a staff member will review everything with you.

Case managers and referring providers may complete this on a client's behalf. Fields marked * are required.

If you are in crisis right now, do not wait for a response to this form.Call or text 988 (Suicide & Crisis Lifeline), call 911, or go to your nearest emergency room. This form is reviewed during business hours and is not monitored around the clock.
1

Client Information

Emergency contact
STAFFScreening completed by

Leave blank if the client is completing this form on their own.

How did you hear about us?
2

Insurance Information

Are you the policy holder?
3

Substance Use History

Answer as accurately as you can. This information is protected and is used to keep you safe during treatment.

How do you use it?
How often do you use it?
When did you last use? *
How long have you been using it?
Is there a second substance you use regularly?
Have you ever overdosed?
Have you ever been on medication-assisted treatment (MAT)?Suboxone, Methadone, Vivitrol, Sublocade
4

Withdrawal History

Have you ever had withdrawal symptoms when you stopped using?
Are you having any withdrawal symptoms right now? *
Have you ever had a seizure from stopping alcohol or benzodiazepines?Benzodiazepines include Xanax, Klonopin, Valium, Ativan
Have you ever had delirium tremens (DTs)?Severe confusion, shaking, or hallucinations during alcohol withdrawal
5

Medical History

Do you have any current medical conditions?
Primary care doctor
Have you ever had a traumatic brain injury or serious head injury?
Have you had seizures that were not related to withdrawal?
Do you have any allergies to medications or foods?
Have you been hospitalized recently, medically or psychiatrically?
6

Behavioral & Mental Health

These questions help us keep you safe. If any of this is hard to answer in writing, leave it blank and tell a staff member instead.

Have you ever had thoughts of ending your life?
Have you ever made an attempt on your life?
Are you having thoughts of ending your life right now? *

If you are having these thoughts right now, please call or text 988, or call 911 if you are in immediate danger.You can also call our office at 210-868-5801 during business hours. Someone from our team will follow up with you, but this form is not monitored around the clock.

Have you ever had thoughts of hurting or killing someone else?
Are you having thoughts of hurting someone else right now? *
Have you ever hurt yourself on purpose without intending to end your life?
Which of these are you currently experiencing?
Symptom
Yes
No
Depression
Anxiety
Panic attacks
Mood swings
Irritability or anger
Hearing things others don't
Seeing things others don't
Feeling paranoid
Trouble sleeping
Have you ever been diagnosed with a mental health condition?
Are you currently seeing a psychiatrist or mental health provider?
7

Trauma History

Have you experienced any traumatic events in your life?
Do you have symptoms of PTSD?

Nightmares, flashbacks, being easily startled, avoiding reminders

8

Legal History

Have you ever been arrested?
Do you have any current legal involvement?
Officer or caseworker we should have on file
9

Living Situation & Support

Where are you living right now?
Does where you're living support your recovery?
Are there concerns at home?
What is your current work or school status?
Do you have reliable transportation to the program?
Are you able to afford your current housing?
10

Treatment History

Which of these have you been through before?
Most recent treatment facility
Why did you leave?
Do you have a copy of your discharge medication list?
11

Your Goals, Strengths & Preferences

Your answers here shape your individualized treatment plan. There are no wrong answers — check what fits and add anything else in your own words.

Strengths — what is going well, or what do you have going for you?
Needs — what do you most need help with?
Abilities — what are you good at, or what do you enjoy doing?
Preferences — how do you want your treatment to work?
12

Release of Information

Do we have your permission to request and share records with the treatment center or hospital you attended?

You'll sign a full release form at admission. This just tells us whether to start the process.

13

Program Schedule & Availability

When the programs meet

PHP (Partial Hospitalization)
Monday through Friday, 12:00 PM – 5:00 PM · Orientation begins at 11:45 AM
IOP (Intensive Outpatient)
Mondays, Tuesdays and Wednesdays, 6:00 PM – 9:00 PM · Orientation begins at 5:45 PM

Transportation is provided through Uber for clients who need it, at no cost to you.

Which schedule works for you?
If you are accepted, how soon could you start? *
Is anything likely to get in the way of attending those hours?
Do you need transportation to and from the program?We arrange and pay for Uber rides for clients who need them

What happens after you submit this

  1. Our clinical team reviews your screening to determine the right level of care.
  2. We call you back with a decision. If you are accepted, we schedule your orientation date at that time.
  3. Before orientation, you set up your patient account in our EHR and complete the questionnaires and consent forms sent to you.
  4. You arrive at orientation — 11:45 AM for PHP, 5:45 PM for IOP — ready to begin.

Your account setup and forms must be finished before you arrive for orientation. We cannot start you in the program without them.

Do you have a working email address and a phone or computer to complete online forms?
14

Program Expectations & Acknowledgment

If you are admitted, you agree to:

  • Participate in all scheduled programming
  • Meet the attendance requirements of your level of care — PHP runs Monday through Friday, 12:00 PM to 5:00 PM; IOP runs Monday, Tuesday and Wednesday, 6:00 PM to 9:00 PM
  • Set up your EHR patient account and complete all assigned questionnaires and consent forms before you arrive for orientation
  • Arrive on time for orientation — 11:45 AM for PHP, 5:45 PM for IOP
  • Complete random drug and alcohol screenings
  • Report all medications you are taking, including anything prescribed elsewhere
  • Follow our emergency response procedures, including calling 911 when needed
  • Complete an individualized treatment plan within 3 days of admission
Who is signing?

Review your answers before submitting. Our intake team reviews submissions during business hours and will reach out to schedule your assessment.

Your answers are confidential and protected under HIPAA and 42 CFR Part 2. Questions? Call 210-868-5801.

Graceland Psychiatric & Neuromodulation Center · 2411 NE Loop 410, Suite 114, San Antonio, TX 78217

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Contact

Call/Text:

210-868-5801

Email:

contact@gracelandpsychiatry.com

Fax:

726-201-1558

11212 State Hwy 151, Plaza 2, Suite 120,
San Antonio, TX 78251

2411 NE Interstate 410 Loop, Suite 114
San Antonio, TX 78217

790 Generations Drive
Suite 210, New Braunfels, TX 78130

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