Pre-Assessment Form

Applicant Information
Name:
 What level of care are you interested in?
RTC PHP IOP Sober Living
Date of birth:
 Age:
 SSN:
Current address:
City:
 State:
 ZIP Code:
Home Phone:
 Cell Phone:
 Email:

Insurance Information
Do you currently have health insurance? Yes No   (If Yes, please complete all of the information below)
Insurance Company:
 Subscriber:
Member ID:
 Group #:
 Phone:
Do you have any secondary health insurance coverage? Yes No
Insurance Company:
 Subscriber:
Member ID:
 Group #:
 Phone:

Referral Information
Name of person or facility:
Address:
 Phone:
City:
 State:
 ZIP Code:
Relationship:

Significant other Information
Name:
Relationship:
 SSN:
 Phone:

Employment Information
Current employer:
Employer address:
 How long?
Phone:
 E-mail:
 Fax:
City:
 State:
 ZIP Code:
Position:
 Hourly Salary Annual income:

Reason for seeking assessment/treatment

Substance abuse history
Substance of Choice Age of First Use How Often Do You Use How Much Do You Use

HAVE YOU BEEN TO TREATMENT PREVIOIUSLY? Yes No
Prior Treatment history
Name of Treatment Center Dates Attended Reason for Discharge Length of Sobriety After Leaving

Other Providers Information
Are you currently under the care of a psychiatrist or therapist? Yes No  (If Yes, please complete all of the information below)
Name:
 Phone:
Address:
 City/State:
 Zip:
Last appt date:
 Reason for appt:
Name:
 Phone:
Address:
 City/State:
 Zip:
Last appt date:
 Reason for appt:

Mental Health Hsitory
Do you have any current psychiatric diagnosis? Yes No   (If Yes, please explain below)

DO YOU CURRENTLY TAKE ANY MEDICATIONS? YES NO
MEDICATIONS
Name of Medication Reason Prescribed Dosage How Long Taking/Prescribing Doctor

Family History
Does anyone in your family have an issue with alcohol or drugs? Yes No   (If Yes, please explain below)

Signatures
I authorize that the information provided on this form is true and correct to the best of my knowledge. I understand that all the information provided is confidential and will not be distributed without my written consent.
Signature of patient:
 Date:
The red fields are required.