Online Enrollment Form
1. What is your name
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2. What is the best number to reach you at
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3. Can we leave a message at this number identifying who we are
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4. What is your email address
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5. What is your relationship with your loved one that we are intervening on
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6. How were you refferred to our team
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7. Why are you concerned about your loved one? Are they abusing drugs and/or alcohol? Is there a mental health concern? Psychosis? Disordered Eating? Sex Addiction? A combination of all of the above? Please share why you reached out to us.
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8. What is the name of your loved one that we are intervening on
Client first nameClient last name
9. Does your loved one have a nickname
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10. What is your loved one's date of birth
Client birthdate
11. What gender does your loved one identify as
Client gender
12. What is your loved one's home address
Client Address
13. Who does your loved one live with
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14. Does your loved one have children
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15. What is your loved one's sexual orientation
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16. What is your loved one's marital status
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17. Does anyone else in your family struggle with substance abuse
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18. Is your loved one abusing drugs
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19. Does your loved one have a mental health diagnosis
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20. If there is no mental health diagnosis, do you have any concerns or suspicions about their mental health
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21. What have you experienced that has you concerned
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22. Has your loved one experienced hallucinations
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23. Has your loved one ever heard voices
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24. Has your loved one ever believed that they were being spied on or followed
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25. Does your loved one have a history of violence toward others
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26. Does your loved one have any formal fight training such as martial arts or boxing
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27. Does your loved one own a gun
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28. Has your loved one ever been arrested
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29. Is your loved one able to travel by plane
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30. Is your loved one able to leave the state
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31. Does your loved one have a history of self harm (example: cutting, burning, pulling out hair)
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32. Has your loved one ever attempted to take their own life
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33. Does your loved one ever have thoughts or made statements about taking their own life
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34. Has your loved one ever made statements about harming someone else
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35. Has your loved one experienced trauma
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36. Has your loved one ever struggled with an eating disorder
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37. Has your loved one ever used substance to control their weight
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38. Has your loved one ever been hospitalized with an eating disorder
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39. Does your loved one binge and purge
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40. Do you feel like your loved one may struggle with sexual addiction
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41. Do you feel your loved one may struggle with a gambling addiction
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42. Is it possible that your loved one is pregnant
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43. Is your loved one physically disabled
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44. Has your loved one experienced contagious health problems such as tuberulosis or pneumonia
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45. Has your loved one ever experienced a stroke
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46. Has your loved one ever suffered from a head injury where they lost conciousness
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47. Has your loved one ever experienced seizures or convulsions
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48. Has your loved one suffered from a heart attack or any problems
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49. Has your loved one ever had a blood clot that required medical attention
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50. Has your loved one ever experienced high blood pressure or hypertension
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51. Does your loved one have a history of cancer
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52. Has your loved one been diagnosed with diabetes
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53. Has your loved one experieneced kidney infections or any problem with their kidneys
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54. Has your loved one ever struggled with incontience
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55. Please list any surgeries your loved one has had over the last 5 years
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56. Has your loved one been hospitalized in the last 6 months for a medical condition
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57. When was the last time your loved one saw a physician
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58. Is your loved one allergic to any medication
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59. Does your loved one have food allergies
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60. Is your loved one taking any over the counter medication
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61. Is your loved one taking any prescribed medication
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62. Has your loved one ver been to treatment before
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63. Name of your loved one's psychiatrist
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64. Phone or Email
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65. Name of your loved one's psychologist
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66. Phone or Email
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67. Name of your loved one's therapist
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68. Phone or Email
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69. Name of your loved one's Internist
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70. Phone or Email
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71. Is there anything you would like us to know about your loved one's current treatment provider
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72. Does your loved one have a valid ID
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73. Is your loved one currently employed
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74. Where does your loved one work
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75. Does your loved one have health insurance
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75.1 What health insurance company are they with
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75.2 Insurance ID number
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75.3 Insurance Group #
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75.4 Insurance Phone Number (800 number found on back of the card usually labeled "Behavioral Health")
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75.5 Is your loved one the subscriber
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76. Name of the financially responsible party
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77. Phone Number
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78. Email address
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79. Address
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80. Loved one's relationship to the financially responsible party
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Who will be joining the intervention
Please feel welcome to invite anyone that would be helping you to make the decision to move forward with an intervention to the intervention consultation.
81. Who will be joining our consultation, please include anyone that is concerened about your loved one
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