Pre-Admission Form

* = Required Information

How did you hear about us? *

Name of Person Filling Out This Form *

Relationship to Client *

Email Address *

Phone Number *

Alternate phone number

What state are you located in? *

Client Information

Age *

Gender *

Date of Birth *

Form of Payment *

Address *

Street Address

City

State

Zip

Emergency Contact

Name *

First

Last

Phone *

Do you give us permission to contact this person in an emergency? *

Yes

Are you a danger to yourself or others? *

Yes

Have you had any past suicide attempts? *

Yes

Describe most recent attempt

In the last 12 months, have there been any thoughts of suicide, along with an intention and plan? *

Yes

Please describe

Currently, are there any thoughts of suicide along with an intention and plan? *

Yes

Have you ever been hospitalized for a mental health condition? *

Yes

Have you ever had a seizure? *

Yes

When was your last seizure and what was the cause?

Are you currently taking anti-psychotic or other psychiatric medication? *

Yes

List medications and reasons

Are you taking the medications as prescribed? *

Yes

No medications prescribed

Do you have any diagnosed medical conditions? *

Yes

Please 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? *

Yes

Please list last 3 dates and discharge reason:

Do you drink alcohol? *

Yes

How much, how often, last use?

Have you abused prescription medications or used street drugs in the past 6 months? *

Yes

Drug, how much, how often, last use?

Date you last used drugs or drank alcohol? *

In the past 6 months, have you been arrested? *

Yes

Are you currently on parole or probation? *

Yes

Please describe *

Briefly describe your relationship with your immediate family: *

In the past 6 months, have you held steady employment? *

Yes

Please describe your willingness to be helped: *

Anticipated date of admission *