- Step 1 of 32

Name *

First

Last

Address

Address Line 1

Address Line 2

City

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Zip Code

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What are the main reasons you are seeking treatment? *

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Where you are completing this form? *

• Home
• Hospital
• Residential Program
• Other

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Where do you reside? *

• On own
• SLE
• Family members home
• Other

Who do you reside with? *

• Self
• Immediate Family
• Extended Family
• Friends
• Roommate
• Unhoused
• Other

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Name of current treatment center *

What level of care are you currently in? *

• RTC
• PHP
• IOP

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Do you have any history of trauma? (Emotional, Sexual, or Physical) *

• Yes
• No

Can you further elaborate on your reported history of trauma? (Emotional, sexual, physical) *

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Do you have any history of being sexually or financially exploited? *

• Yes
• No

Please Explain

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Do you have a history of Suicide Attempts? *

• Yes
• No

How many SA have you had in your lifetime?

When was your last Suicide Attempt?

What was the result in your last SA (example, hospitalization, ICU, etc.)

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Have you ever put yourself or someone else in harms way as a result of your mental health symptoms? *

• Yes
• No

Please explain: *

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Are you currently under the care of a physician for pain management? *

• Yes
• No

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Do you have any history of substance abuse? (Drugs or Alcohol) *

• Yes
• No

Please explain in more detail: *

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Last date of use and what substance or Drug of choice? *

Are you currently engaged in AA/NA or other sober support networks? *

• Yes
• No

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Have there been negative consequences due to your substance use? *

• Yes
• No

Please explain in a bit more detail *

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Are you open to trying anti craving medications? *

• Yes
• No

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Do you have a history of using MAT/anti-craving medications? *

• Yes
• No

How long were you on this medication and when were you prescribed? When did you stop taking this medication? *

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Are you currently experiencing any withdrawal symptoms? *

• Yes
• No

Please select any current withdrawal symptoms you are experiencing.

• Nausea
• Tremors
• Body
• Aches
• Restless Legs
• Excessive Yawning
• Runny Nose
• Diarrhea
• Abdominal Cramps
• Vomiting
• Sweats
• Chills
• Agitation
• Increased Appetite
• Constipation
• Poor Appetite
• GI Complaints
• Dizziness
• Restlessness
• Headaches
• Anxiosness
• Unsteady Gait
• Hypersensitivity to light
• Hypersensitivity to Noise
• Music/Body aches
• Other - Not Listed

Additional Symptoms not listed? *

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Do you have a history of overdosing? *

• Yes
• No

Please describe when this occured, the substances used, and what happened after *

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Have you been hospitalized in the past year? *

• Yes
• No

What are the dates of your hospitalization? *

Was your visit voluntary or involuntary? *

• Voluntary
• Involuntary

What was the name of the hospital, the reason for the visit, & the outcome? *

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Are you currently working with any outpatient provider (Psychiatrist, psychologist, therapist, etc.) *

• Yes
• No

Name of the provider *

How long have you been working with this provider? *

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Are you currently taking any prescribed medications? *

• Yes
• No

What medications are you currently taking, how many times per day, and what dosage? *

Will you need us to provide these medications?

• Yes
• No

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Do you have any history of eating disorders? *

• Yes
• No

Please briefly describe what eating disorders you are/were struggling with? *

Were the eating disorders ever diagnosed by a physician? *

• Yes
• No

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Do you have any active diagnosis? *

• Yes
• No

What were the diagnosis, what year were you diagnosed, & who was the diagnosing physician? *

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Will you need assistance with Disability, FMLA, SSI? *

• Yes
• No

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Are you currently employed? *

• Yes
• No

Job position type? *

• Full time
• Part time

What is your current work schedule? *

How long have you been employed and in what position? *

Are you at risk for losing employment? *

• Yes
• No

Explain why? *

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What is your highest level of education? *

Are you currently enrolled as a student? *

• Yes
• No

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Have you ever been placed on academic suspension or expelled? *

• Yes
• No

Details (Incident that resulted in suspension or expulsion) *

Onset (When did this occur) *

Duration (How long did this last, is it still ongoing)? *

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Who is your guardian? *

Any issues with school? *

• Yes
• No

Please describe *

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What grade are you in? *

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Are you currently in any learning assistance programs? (IEP 504, etc...) *

• Yes
• No

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Do you require technology needs? Examples: Hearing Aids Visual Aids Physical Other *

• Yes
• No

List below *

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Do you require assistance to communicate, read, or write in English? *

• Yes
• No

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Do you have the means and ability to complete a Telehealth program? *

• Yes
• No

Submit