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Pre-Admission Screening

Please be as descriptive as possible. We can provided better treatment with an in-depth, correct answers.


SelfParentGuardianOther Contact



City

State

Zip Code

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Insurance Infomation


SelfOtherNone/Self Pay

YesNo


City

State

Zip Code

Substance Abuse History

Please describe substance one below


YesNo



YesNo



YesNo



YesNo



YesNo

Substance Abuse Treatment History


NoYes

Most Recent



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Mental Health


NoYes

Most Recent




Please elaborate on any additional details not covered above.


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Medical History


NoYes


NoYes


NoYes


NoYes


NoYes


NoYes


NoYes


NoYes

Emotional/Behavioral Risk Screening


NoYes


NoYes


NoYes


NoYes


NoYes


NoYes


NoneSelfSpouseSignificant OtherFamily

Legal Issues Past and Current


NoYes


NoYes

Effect/Impact ON

How has your drinking / using affected the following areas of your life?


NewspaperRadioTV CommercialInternet SearchWebsiteAnother TreatmentTherapist/DoctorOther

Admission Application

You can speed up the admissions process by submitting your pre-admissions screening online.

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