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 Number What 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* 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?* Yes No Are you a danger to yourself or others?* Yes No Have you had any past suicide attempts?* Yes No If yes please describe most recent attemptIn the last 12 months, have there been any thoughts of suicide, along with an intention and plan?* Yes No If yes please describeCurrently, are there any thoughts of suicide along with an intention and plan?* Yes No Have you ever been hospitalized for a mental health condition?* Yes No Are you currently taking medications for a mental health condition?* Yes No Are you taking the medications as prescribed?* Yes No No medication prescribed Do you have any diagnosed medical conditions?* Yes No Please 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?* Yes No Briefly 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?* MM slash DD slash YYYY CAPTCHA*Please only click submit once while the form processesPhoneThis field is for validation purposes and should be left unchanged.
