| Date (mm/dd/yy): |
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| Full name: |
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| Phone: |
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| Best Time to Call: |
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| Address: |
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| State: |
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| Date of Birth (mm/dd/yy): |
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Age:
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Sex: M
F
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| Emergency contact: |
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Relation:
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| Your e-mail: |
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| Reason for seeking treatment |
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| Substance(s): |
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How long using?
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| How much? |
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How often?
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Has your drug use ever resulted in medical or legal problems?
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YES
NO
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| Have you ever been treated for substance dependence or misuse (eg, detoxification program)? |
YES
NO
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| Please describe: |
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| Have you ever tried to quit on your own? |
YES
NO
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| Please describe: |
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| Please list all medications you are taking or have taken in the past two weeks (OTC and prescription): |
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| Have you ever been treated by a psychiatrist? |
YES
NO
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| Please describe treatment reason, setting, and length: |
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Does anyone in your family (mother, father, brother/sister, child, aunt/uncle or grandparent) have a history of substance abuse? |
YES
NO
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| Please describe: |
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Are you allergic to any medication, substance or food?
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| Do you have any medical conditions (diabetes, heart disease, seizures, HIV+, epilepsy, STDs)? |
YES
NO
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| Please describe: |
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| Are you currently taking any medications to treat these conditions? |
YES
NO
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| List medication and dosage Include contraceptives: |
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| Are you pregnant? |
N/A
NO
YES
NOT SURE
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| Are you currently employed? |
YES
NO
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How many hours a week (avg)?
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Please describe your current living arrangements: |
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| Do you need a special diet or accommodation arrangements? |
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Other: |
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| Preferred treatment Date (mm/dd/yy): |
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