Pre-Admission Assessment

Personal and Financial Information

Name:

 

Address:

 

City:

 

SSN:

 

ST/Zip:

 

DOB:

 

County: Phone:

 

In or out of region:

 

Occupation: Employer:

 

Currently Employed:Length of Employment:

 

Is their job in jeopardy:

Personal Monthly Income:Number in Household:

 

Total Household Income:

 

Insurance Information

Medical Insurance:Contract Number:

 

Group Number:Customer Service #:

 

Deductible:Verified:

 

Identification

Driver’s License #:

 

State Issued:

 

Suspended:Picture ID (yes /no):

 

State Issued:SS Card (yes/no):

 

Medical Information

Primary Care Physician:Address:

 

Phone:Prescription Medications (y/n):

 

If yes, list all medications currently taking:

 

Does client take as prescribed:

 

Current Medical Conditions: Physical Disability  Diabetes  Emphysema/COPD  Allergies

Contagious Disease  Heart Condition  Seizures  Hypertension  Pregnant   Hepatitis

STD/HIV  TB  Cancer

 

If yes to any of the above, please explain:

 

 

 

Alcohol and Drug Use History

Precipitating Crisis:

Drug/ Substance of Choice

Age of first use

How often used

How much used

Last used

Route of Administration

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Cravings:Hx of Blackouts:

 

Hx of w/d seizure:

 

History of withdrawal (explain):

 

Psychiatric History

Is there a history of the following:  Depression  Anxiety  Hallucinations  Suicidal Thoughts

Homicidal Thoughts  Self-Mutilation  Eating Disorders  Family Mental Health Dx:

Victim of Abuse   Prior MI diagnosis  Prior IMP  Compulsive Sexual Behaviors

 

If yes to suicidal thoughts: Prior Attempt (y/):Number of attempts:Date of last attempt:

Current Thoughts (y/n): Current Plan (y/n):Current Intent (y/n):

 

If yes to any other, please explain in detail:

 

Treatment History

Has client been to tx in the past:How many times:

Date of last tx:

Type of treatment:   OPIOPPHPResDetox

NA/AA Participation:Sponsor:

Longest period of sobriety:

Consequences of use:

 

Does the client relate to the severity of his/her disease:

Insight:Judgment:

 

Legal History

Current legal issues:Hx of Legal Issues:

DUI Offender:

If current legal issues, what is the charge:

Court Date:Do you have a probation officer:

Name and Contact information:

 

Recovery Environment

Marital Status:Does spouse use:

Is spouse supportive:Who does client live with:

Does client have children:Ages:

Who is caring for children now:DHS Involved:

Does anyone in the home use drugs:Who will be involved in tx:

Was an ultimatum given:By whom:

Highest Grade Completed:

 

Staff Use Only

Projected Admit Date:Admission Fee:

Fee Approved by:Therapist Assigned:

Precert Info: