Rehab Treatment Pre-AdmissionA Staff Member will Contact You After you have Completed the Pre-Admission Application to Answer any Questions and Continue the Process.Fields marked * are required.How Did You Hear About Us?*GoogleBingYahooYelpPsychology TodayThe Addictions AcademyInterventionistRadioFriendFamilyTherapistDoctorAlumniReAdmitOtherIf Other, How Did You Hear About Us?Name of Person Filling Out This Form*Relationship to Client*SelfFamilyFriendReferentEmail Address* Phone Number*Alternate Phone NumberWhat state are you located in?* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Client InformationClients Legal Name* First Last Client Phone Number*Age*18192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleForm of Payment*Self-PayInsuranceAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactName* First Last Phone*Do you give us permission to contact this person in an emergency?*YesNoAre you a danger to yourself or others?*YesNoHave you had any past suicide attempts?*YesNoIf yes please describe most recent attemptIn the last 12 months, have there been any thoughts of suicide, along with an intention and plan?*YesNoIf yes please describeCurrently, are there any thoughts of suicide along with an intention and plan?*YesNoHave you ever been hospitalized for a mental health condition?*YesNoHave you ever had a seizure?*YesNoIf Yes, When was your last seizure and what was the cause?Are you currently taking antipsychotic or other psychiatric medication?*YesNoList Medications and reasonsAre you taking the medications as prescribed?*YesNoNo medication prescribedDo you have any diagnosed medical conditions?*YesNoPlease list any immediate medical concerns or conditions*Please list any and all medications you are currently taking or prescribed.Have you attended any drug and alcohol treatment centers in the past?*YesNoPlease list last 3, dates and discharge reason:Do you drink alcohol?*YesNoHow much?*How often?*Last use?*Have you abused prescription medications or used street drugs in the past 6 months?*YesNoWhat drug?*How much?*How often?*Last use?*Date you last used drugs or drank alcohol?* Date Format: MM slash DD slash YYYY In the past 6 months, have you been arrested?*YesNoAre you currently on parole or probation?*YesNoPlease describe*Have you ever been convicted of a sex crime?*YesNoPlease describe*Briefly describe your relationship with your immediate family:*In the past 6 months, have you held steady employment?*YesNoPlease describe your willingness to be helped:*Anticipated date of admission?* Date Format: MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged. If you have any Questions about our Comprehensive and Holistic Approach to Treatment, you can Contact Us to get the Information you Need!