Pre-Admission Screening Form

Please describe substance one below

Do you need to add more substances?*
NoYes

Have you received mental health services or are you currently receiving services?*
NoYes

Have you ever been to treatment for substance abuse?*
NoYes

Do you have any history of withdrawal symptoms?*
NoYes

Do you have any medical conditions?*
NoYes

Have you been hospitalized in the past 30 days?*
NoYes

Any physical limitations or challenges to activities of daily living(medical devices, dietary):*
NoYes

Do these conditions require daily supervision?*
NoYes

Allergies (medications/environment/seasonal)?*
NoYes

Are you currently taking any medications?*
NoYes

Are there any Medications that are prescribed to you that you aren't taking?*
NoYes

Are you currently having suicidal thoughts?*
NoYes

Have you thought about or attempted suicide in the past year?*
NoYes

Have you ever been hospitalized due to a suicide attempt?*
NoYes

Do you have a history of self-injuring/mutilation?*
NoYes

Do you have issues with anger?*
NoYes

Do you act out when angry?*
NoYes

Any violence toward:*
NoneSelfSignificant OtherFamilyOther

Do you have any current legal issues?*
NoYes

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

Your spouse or significant other:

Your family (parents, children):

Your friends:

Your job or education:

What is your occupation?:

How did you hear about us?:

NewspaperRadioTV CommercialInternet SearchWebsiteAnother TreatmentTherapist/DoctorOther