Name: *

First Name

Last Name

Primary Phone Number:

(###)

###

####

Secondary Phone Number:

(###)

###

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Gender:

Male

Female

Transgender

Gender Fluid

Other

Marital Status:

Single

Married

Domestic Partner

Widowed

Children:

Yes, living with me

Yes, not living with me

No

Do you drink alcohol?

Yes

No

Previous attempts at recovery? *

Yes

No

Any emergency room visits or hospitalizations within past year for medical, psychiatric or substance abuse?

Yes

No

Reason for hospitalization:

Detox

Overdose

Suicide Attempt

Other

Any suicide attempts in the last year?

Yes

No

What is motivating you to seek treatment at this time?

Recent problem or crisis

External pressures (legal, financial family)

Feel it's time to get help

Other

Emergency Contact: *

First Name

Last Name

Emergency Contact Phone Number: *

(###)

###

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