Missouri Community Options and Resources Screening Tool
Welcome to the Missouri Community Options and Resources Screening Tool!
This screening tool was designed to quickly evaluate your service needs and refer you to the place that can best help you meet those needs. It will take just a few minutes to complete.
All questions are worded from the point of view of the person seeking services for him- or herself. However, if you are looking for services for someone else, you can still use this assessment - just fill it out with the information that is true for the person you have in mind.
Once you have finished answering the questions on the screening tool, a Specialist will review your answers and contact you regarding what types of help may be available. By submitting a Screening Tool, you agree to let our Partners begin an initial assessment and prepare information before contacting you.
The information that you provide us is treated with the highest levels of security and confidentiality!
All questions are worded from the point of view of the person seeking services for him- or herself. However, if you are looking for services for someone else, you can still use this assessment - just fill it out with the information that is true for the person you have in mind.
INFORMATION FOR PERSON NEEDING ASSISTANCE
First Name Middle Initial
Last NameSuffix
Street Address
Post Office Box/
Apartment Number
City StateZip Code
County of Residence
Phone Number
Email Address
Date of Birth
Department Client Number (DCN)
Social Security Number
If you are completing this for someone other than yourself and agree to be contacted, please complete the following:
Name
Contact Phone Number
Email Address
[Information from the fields above will be sent to referral agency]
All questions are worded from the point of view of the person seeking services for him- or herself. However, if you are looking for services for someone else, just answer the questions with the information that is true for the person you have in mind.
Do you have MO HealthNet (Medicaid) coverage? YES NO
[If yes, go to next screen; if no, the following question pops-up]
Do you wish to apply for MO HealthNet (Medicaid) coverage? YES NO
[If yes, continue to next screen; if no, the following screen pops-up and the individual can only go back to the MOCOR Home Page]
[Information will be sent to the referral agency]
Do you have a developmental disability (intellectual disability [“mental retardation”], cerebral palsy, autism, a seizure disorder, or birth defects)?
YES[If yes is selected, the following screen pops up]
NO[If no is selected, continue to next screen]
HAVE YOU BEEN DIAGNOSED AS HIV POSITIVE?
YES[If yes is selected, the following screen pops up]
NO[If no is selected, continue to next screen]
DO YOU HAVE A PHYSICAL DISABILITY AND ARE UNDER AGE 21?
YES[If yes is selected, the following screen pops up]
NO[If no is selected, continue to next screen]
DO YOU HAVE A PHYSICAL DISABILITY AND ARE AGE 21 TO 60 YEARS OLD?
YES[If yes is selected, the following screen pops up]
NO[If no is selected, continue to next screen]
HAVE YOU:
- HAD PROBLEMS WITH MENTAL HEALTH THAT KEPT YOU FROM COMMUNICATING WELL WITH OTHERS, TAKING CARE OF YOURSELF, OR MANAGING YOUR FINANCES?
- HAD DIFFICULTIES WITH EMOTIONAL OR MENTAL HEALTH THAT MADE IT DIFFICULT FOR YOU TO DO YOUR WORK OR SCHOOL, TAKE CARE OF THINGS AT HOME OR GET ALONG WITH OTHER PEOPLE?
- EVERBEEN SEEN IN A PSYCHIATRIC EMERGENCY ROOM OR BEEN HOSPITALIZED FOR PSYCHIATRIC OR MENTAL HEALTH REASONS?
YES[If yes is selected, the following screen pops up]
NO[If no is selected, continue to next screen]
HAVE YOU:
- EVER HAD A DRINK OR USED DRUGS FIRST THING IN THE MORNING TO STEADY YOUR NERVES OR TO GET RID OF A HANGOVER?
- EVER FELT YOU SHOULD CUT DOWN ON YOUR DRINKING OR DRUG USE?
- BEEN ANNOYED BY PEOPLE WHO CRITICIZE YOU FOR DRINKING OR DRUG USE?
- EVER FELT BAD OR GUILTY ABOUT DRINKING OR DRUG USE?
YES[If yes is selected, the following screen pops up]
NO[If no is selected, continue to next screen]
ARE YOU AGE 60 OR OLDER?
YES[If yes is selected, the following screen pops up]
NO[If no is selected, continue to next screen]
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Missouri Community Options and Resources Screening Tool
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