Intake Assessment

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

Client Information

Name(Required)
MM slash DD slash YYYY
Address(Required)
Can we contact the client?(Required)

Payment Information

Do you have insurance you wish to access for possible reimbursement?
MM slash DD slash YYYY

Current Environment

Current Use/Substance History
Substance
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?
Medications
Medication name
Dosage
Frequency
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

Address
Can we contact this contact?

Additional Contact Information

Address
Can we contact this contact?

Begin Your Path to Recovery

Your path towards a satisfying life, free from addiction, begins with a single step. At Ascend Recovery, we are committed to providing you with compassionate care and evidence-based treatment that is essential in rebuilding and reclaiming your life. With a customized approach to recovery, we support you every step of the way. From residential treatment to independent living, we ensure that you have the necessary tools and knowledge to thrive in your new beginning. Don’t let another day pass you by without realizing what could be. Contact us now and take the first step towards a future filled with hope and possibilities.

Take the First Step

Company

Stay Connected

Facebook Twitter Youtube Instagram Linkedin

1 (877) 527-2363

Copyright © 2024 Ascend Recovery. All Rights Reserved.