Person Completing Form

Phone 2:

Client Information

Drug(s) of Choice & Usage Patterns

Alcohol/Drug Treatment History
Have you completed a thirty day program? Yes No

Did you complete the
treatment program?

Current Medications

Medical & Psychiatric Information

What medical problems do you have?

Do you suffer from chronic physical pain? Yes No
If so, how is your pain managed?

Have you been hospitalized or ill in the past 30 days? Yes No
If so, please explain:

Do you have any allergies?

Are you currently under the care of a psychologist, psychiatrist, or therapist?
Yes No
If so, who and why?

Have you been under the care of other psychologists, psychiatrists, or therapists in the past?
Yes No
If so, explain:

Have you ever attempted suicide? Yes No
Date of most recent suicide attempt?

Do you experience physical outbursts of anger? Yes No

Do you experience difficulty with mood swings? Yes No

Do you have trouble sleeping? Yes No

Do you feel down or sad often? Yes No

Do you isolate yourself socially? Yes No

Do you have legal problems pending because of your drug/alcohol use? Yes No

Do you have work-related problems because of your drug/alcohol use? Yes No

Do you have family/marital problems because of your drug/alcohol use? Yes No

Do you have a family history of mental illness? Yes No

Do you have a family history of addiction to alcohol or drugs? Yes No

Do you need any help caring for yourself? Yes No

Employment & Financial Information

Are you currently employed? Yes No
Where?

How do you plan to pay for treatment? Cash Check Credit Card Insurance Unknown
Name of Insurance company: