Gooden Center
A residential drug treatment center for men located in Pasadena, CA. The Gooden Center is a proud member of the National Association of Addiction Treatment Providers (NAATP).

(626) 356-0078
191 North El Molino Avenue Pasadena, CA 91101 US

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Pre-Assessment Form

Applicant Information
Name:
What level of care are you interested in? RTCPHPIOPSober 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? YesNo   (If Yes, please complete all of the information below)

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:
HourlySalaryAnnual income:

Reason for seeking assessment/treatment

Substance abuse history
Substance of ChoiceAge of First UseHow Often Do You UseHow Much Do You Use

HAVE YOU BEEN TO TREATMENT PREVIOIUSLY? YesNo

Other Providers Information
Are you currently under the care of a psychiatrist or therapist? YesNo (If Yes, please complete all of the information below)

Mental Health Hsitory
Do you have any current psychiatric diagnosis?YesNo   (If Yes, please explain below)

DO YOU CURRENTLY TAKE ANY MEDICATIONS? YesNo

Family History
Does anyone in your family have an issue with alcohol or drugs? YesNo   (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. Please leave this field empty.