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Demographics

Name:*

Referral Source:

Date of Birth:*

Age:

Address:

City:

Zip Code:

Country:

State:

Province:

Email:*

SSN:

Phone Number:*

May we leave a message?:

Yes No

Marital Status:

Single Married Divorced Widowed

Insurance Information

Medical Insurance Provider:

Insurance ID Number:

Name of Provider:

Treatment

Service Requested:

Substance Abuse Mental Health

Reason for Requesting Service:

Are you currently receiving medication assisted treatment?:

Are you experiencing any withdrawal symptoms?:

Yes No

Explain:

Current Substance Use 1

Substance:

Last Used:

Frequency of Use:

Current Substance Use 2

Substance:

Last Used:

Frequency of Use:

Current Substance Use 3

Substance:

Last Used:

Frequency of Use:

Current Substance Use 4

Substance:

Last Used:

Frequency of Use:

Medical

Are you pregnant?:

Yes No

Please Explain:

Do you have any known medical issues or concerns?:

Yes No

Please Explain:

Medications 1

Medications:

Dosage:

Medications 2

Medications:

Dosage:

Medications 3

Medications:

Dosage:

Medications 4

Medications:

Dosage:

Primary Care Physician

Name:

Phone Number:

Other Physician

Name:

Phone Number:

Are you currently having any suicidal or homicidal thoughts?:

Yes No

Have you ever attempted suicide?:

Yes No

Legal

Are you on probation/parole?:

Yes No

Reason:

How long?:

Location and PO Name:

Are you involved with Children and Family Services?:

Yes No

Reason:

Location and Case Worker Name:

Have you ever been convicted of a violent crime?:

Yes No

What were the crimes, where were you convicted and when was the conviction. (if mulitple, write detailed answers for each):

Have you ever been convicted of a sexual crime?:

Yes No

What were the crimes, where were you convicted and when was the conviction. (if mulitple, write detailed answers for each):

Housing History and Needs

Last Known Address 1

Address:

City:

Zip Code:

Country:

State:

Province:

Years Lived:

Roomates or Family:

Reason for Leaving:

Last Known Address 2

Address:

City:

Zip Code:

Country:

State:

Province:

Years Lived:

Roomates or Family:

Reason for Leaving:

Last Known Address 3

Address:

City:

Zip Code:

Country:

State:

Province:

Years Lived:

Roomates or Family:

Reason for Leaving:

Have you ever lived in Recovery Housing?:

Yes No

When, where, dates and reason for leaving:

Signature:

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