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Pre-Admission Screening

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


SelfOther Contact



City

State

Zip Code

NoYes

Insurance Infomation


SelfOtherNone/Self Pay

YesNo


City

State

Zip Code

Substance Abuse History


Please describe substance one below


YesNo



YesNo



YesNo



YesNo



YesNo

Mental Health


NoYes



Please elaborate on any additional details not covered above.


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Please elaborate on any additional details not covered above.


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Please elaborate on any additional details not covered above.


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Please elaborate on any additional details not covered above.


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Please elaborate on any additional details not covered above.

Substance Abuse Treatment History


NoYes


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Check box to add another


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Medical History


NoYes



NoYes



NoYes



NoYes



NoYes



NoYes



NoYes



NoYes


Emotional/Behavioral Risk Screening


NoYes



NoYes



NoYes



NoYes



NoYes



NoYes



NoneSelfSignificant OtherFamilyOther

Legal Issues Past and Current


NoYes


Effect/Impact On

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


NewspaperRadioTV CommercialInternet SearchWebsiteAnother TreatmentTherapist/DoctorOther

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