Admission Form
Person Completing Form
First Name
Middle Name
Last Name
Relationship to patient
Phone One e.g. XXX-XXX-XXXX
Phone Two e.g. XXX-XXX-XXXX
Email
Address
City
State
Zipcode
Client Information
First Name
Middle Name
Last Name
SS #
Date of Birth
Gender
Male
Female
Is client pregnant?
No
Yes
If so, how many months along
Phone e.g. XXX-XXX-XXXX
Email
Address
City
State
Zipcode
Drug(s) of Choice & Usage Patterns
1st Drug
Name of Drug
Age of first use
Date of last use
How much/often?
2nd Drug
Name of Drug
Age of first use
Date of last use
How much/often?
3rd Drug
Name of Drug
Age of first use
Date of last use
How much/often?
4th Drug
Name of Drug
Age of first use
Date of last use
How much/often?
Add Another
Alcohol/Drug Treatment History
1st Treatment
Start Date
End Date
Did you complete the treatment program?
No
Yes
Where?
Type of treatment: (residential, outpatient, inpatient, etc.)
2nd Treatment
Start Date
End Date
Did you complete the treatment program?
No
Yes
Where?
Type of treatment: (residential, outpatient, inpatient, etc.)
3rd Treatment
Start Date
End Date
Did you complete the treatment program?
No
Yes
Where?
Type of treatment: (residential, outpatient, inpatient, etc.)
4th Treatment
Start Date
End Date
Did you complete the treatment program?
No
Yes
Where?
Type of treatment: (residential, outpatient, inpatient, etc.)
5th Treatment
Start Date
End Date
Did you complete the treatment program?
No
Yes
Where?
Type of treatment: (residential, outpatient, inpatient, etc.)
Add Another
Current Medications
1st Medication
Name of Medication
Dosage & Frequency
Prescribing Physician
Reason for Medication
2nd Medication
Name of Medication
Dosage & Frequency
Prescribing Physician
Reason for Medication
3rd Medication
Name of Medication
Dosage & Frequency
Prescribing Physician
Reason for Medication
4th Medication
Name of Medication
Dosage & Frequency
Prescribing Physician
Reason for Medication
Add Another
Medical & Psychiatric Information
What kind of treatment is client applying for?
PRIMARY
IOP
What medical problems do you have?
Do you suffer from chronic physical pain?
No
Yes
If so, how is your pain managed?
Have you been hospitalized or ill in the past 30 days?
No
Yes
If so, please explain
Do you have allergies?
Are you currently under the care of a psychologist, psychiatrist, or therapist?
No
Yes
If so, who and why?
Have you been under the care of other psychologists, psychiatrists, or therapists in the past?
No
Yes
If so, explain
Have you ever attempted suicide?
No
Yes
Date of most recent suicide attempt?
Do you experience physical outbursts of anger?
No
Yes
Do you experience difficulty with mood swings?
No
Yes
Do you have trouble sleeping?
No
Yes
Do you feel down or sad often?
No
Yes
Do you isolate yourself socially?
No
Yes
Do you have legal problems pending because of your drug/alcohol use?
No
Yes
Do you have work-related problems because of your drug/alcohol use?
No
Yes
Do you have family/marital problems because of your drug/alcohol use?
No
Yes
Do you have a family history of mental illness?
No
Yes
Do you have a family history of addiction to alcohol or drugs?
No
Yes
Do you need any help caring for yourself?
No
Yes
Employment & Financial Information
Are you currently employed?
No
Yes
Where?
What kind of insurance does client have?
How does client plan on paying for treatment?
OUT-OF-POCKET
INSURANCE
MEDICARE/MEDICAID
OTHER
Referral Information
How did you hear about our treatment facility?
