Intake Assessment

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Prospective Client’s Name(Required)
Name of person filling out form (if different) than client(Required)

Client Information

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Can we contact the client?(Required)

Payment Information

Do you have insurance you wish to access for possible reimbursement?
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Current Environment

Current Use/Substance History
Amount / Frequency
Last Use Date
Route of Administration

Relapse, Continued Use

Prior treatments?
Prior treatment details
What level of care?
How long were you there?
How long did you remain clean / sober after?

Medical History

Have you been hospitalized in the past 90-days?
Are you taking any medications?
Medication name
Reason for taking the medication
Have you lost your appetite?
Have you lost or gained weight recently?
Do you have any difficulty walking distances?
Trouble sleeping?
Memory loss?

Mental Health History

Have you experienced any childhood and/or adulthood trauma?
Have you ever harmed yourself (cutting, burning, etc.…)?
Have you ever had thoughts of hurting someone?
Do you have an eating disorder (anorexia, bulimia, over eating)?
Have you had any previous Mental Health Diagnosis (thought disorder, personality disorder, mood disorder)?
Have you ever experienced psychosis or delusions?
Were you hospitalized due to psychosis?
Has an injectable medication ever been recommended or prescribed?

Emergency Contact Information

Can we contact this contact?

Additional Contact Information

Can we contact this contact?