Admissions Form General InformationFirst Name(Required)Last Name(Required)Date of Birth(Required)Gender(Required)Address(Required)City(Required)State(Required)Zip(Required)Phone number(Required)E-mailSubstance Use HistoryPrimary drug of choiceLast date of use (approximately)Additional drug of choice (if any)When are you looking to get into treatment?Will you require transportation assistance? Yes No Medical and Mental Health HistoryAre you pregnant? Yes No Not Applicable Do you have diabetes? Yes No Do you have a history of seizures? Yes No Do you currently have any medical conditions or concerns? Yes No If yes to medical conditions, please list hereDo you have open sores, wounds, or lesions? Yes No Have you been tested for MRSA? Yes No Do you have a history of stroke or elevated blood pressure? Yes No Have you had a recent injury, illness, or accident? Yes No Are you capable of self-care? ex: eating, walking, dressing ect. Yes No Are you on (MAT) Medication Assisted Treatment? Yes No Are you capable of getting in and out of a 7-12 passenger van? Yes No Do you need durable medical equipment? Yes No Do you have any mental health conditions or concerns? Yes No If yes, please explainDo you have a history of self-harm or harm to others? Yes No If yes, please explainDo you have any known food or drug allergies? Yes No If yes, please list hereDo you currently take prescribed medication(s)? Yes No If yes, please list hereAre you capable of self-administrating medication as prescribed? Yes No Health InsuranceDo you currently have health insurance coverage? Yes No Insurance companyInsurance policy numberDate of expirationDo you currently have a source of income? Yes No Household/Family sizeEmergency Contact InformationEmergency contact: First & last nameEmergency contact: Phone numberRelationship to clientLegal Representative, Power of Attorney, Protective PayeeDo you have a legal representative, power of attorney, or protective payee? Yes No CommentsCAPTCHA
