Pre-Admission (Mental Health) Fields marked * are required. How Did You Hear About Us?*GoogleBingYahooYelpPsychology TodayThe Addictions AcademyInterventionistRadioFriendFamilyTherapistDoctorAlumniReAdmitOtherIf Other, How Did You Hear About Us?Are You First Responder?YesNoName of Person Filling Out This Form*Relationship to Client*SelfFamilyFriendReferentEmail Address* Phone Number*Alternate Phone NumberWhat state are you located in?* AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Client InformationClients Legal Name* First Last Client Phone Number*Age*18192021222324252627282930313233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990Date of Birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleForm of Payment*Self-PayInsuranceAddress* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactName* First Last Phone*Do you give us permission to contact this person in an emergency?*YesNoAre you a danger to yourself or others?*YesNoHave you had any past suicide attempts?*YesNoIf yes please describe most recent attemptIn the last 12 months, have there been any thoughts of suicide, along with an intention and plan?*YesNoIf yes please describeCurrently, are there any thoughts of suicide along with an intention and plan?*YesNoHave you ever been hospitalized for a mental health condition?*YesNoAre you currently taking medications for a mental health condition?*YesNoAre you taking the medications as prescribed?*YesNoNo medication prescribedDo you have any diagnosed medical conditions?*YesNoPlease list any immediate medical concerns or conditions*Please list any and all medications you are currently taking or prescribed.Do you use alcohol or other substances?*YesNoBriefly describe your pattern of useWho is your support* Mother Father Family member Friend Wife Husband Girlfriend Boyfriend Other Briefly describe your relationship with your immediate support:*Anticipated date of admission?* Date Format: MM slash DD slash YYYY CAPTCHA*Please only click submit once while the form processesEmailThis field is for validation purposes and should be left unchanged.
