Tribe Recovery Homes Intake Questions

Tribe Recovery Homes LLC. Intake Questions

1. Participant information:

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Intake Date: Date

Gender: Client gender 

Birthdate: Client birthdate

Previous/Family Members/Partners Street Address:Text field

Address: Client Address

City: Client City State: Client State Zip: Client Zip

Sobriety Date: Client sobriety date

 

Social Security#: Text field

E-mail: Client email

Highest level of education completed:

Education 1 degree

Cell phone:  Client phone


Please indicate which method of contact is preferred and if it is ok to leave a message:

Text field

Is it ok to leave a message?

Checkboxes


Emergency Contact Info Including Contact Number:

Name: Contact 1 name

Phone: Contact 1 phone

Relation: Contact 1 type

Is it ok to leave a message?

Checkboxes

 

2. Have you received help for drug or alcohol dependency? If yes, please specify when, for what and where:

Paragraph

 

3. Which - if any - of these substances do you currently use or have used in the past? Please use the box to indicate
your age at first use and age at last use. (E.g.: Alcohol - 16, 30)

Checkboxes Alcohol
Text field

Checkboxes Amphetemines
Text field

Checkboxes Opiates
Text field

Checkboxes Heroin
Text field

Checkboxes Methamphetamine
Text field

Checkboxes Barbiturates
Text field

Checkboxes Caffeine
Text field

Checkboxes Cocaine
Text field

Checkboxes Crack cocaine
Text field

Checkboxes Hallucinogens (e.g., LSD)
Text field

Checkboxes Inhalants (e.g., glue, gas)
Text field

Checkboxes Marijuana or hashish
Text field
Checkboxes Nicotine/cigaretters
Text field

Checkboxes PCP
Text field

Checkboxes If "other(s)", please specify
Text field


4. Have you received psychotherapy or counseling in the past? If yes, when was that? Please list the mental health care
providers (Counselor / Psychologist / Psychiatrist)' names and phone numbers:

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5. If any, which have been the consequences of substance abuse in your life? Please use the box below to explain such
consequences:

Checkboxes


If "other(s)", please specify
Text field

6. Describe your current physical health:
Radio buttons


7. If you are currently under care of a Physician, please specify:

Physician: Condition: Treatment:
Text field Text field Paragraph
Text field Text field Paragraph
Text field Text field Paragraph

 

8. Which medications (psychotropic or not) are you currently taking?

Medication #1

Medication: Medication 1 name Dosage: Medication 1 dosage

Quantity: Medication 1 quantity Category: Medication 1 category

Frequency: Medication 1 frequency MD: Medication 1 md

Pill count: Medication 1 pill count Discontinued at: Medication 1 discontinued at

Adverse effects: Medication 1 notes

Since when: Text field

Medication #2

Medication: Medication 2 name Dosage: Medication 2 dosage

Quantity: Medication 2 quantity Category: Medication 2 category

Frequency: Medication 2 frequency MD: Medication 2 md

Pill count: Medication 2 pill count Discontinued at: Medication 2 discontinued at

Adverse effects: Medication 2 notes

Since when: Text field

Medication #3

Medication: Medication 3 name Dosage: Medication 3 dosage

Quantity: Medication 3 quantity Category: Medication 3 category

Frequency: Medication 3 frequency MD: Medication 3 md

Pill count: Medication 3 pill count Discontinued at: Medication 3 discontinued at

Adverse effects: Medication 3 notes

Since when: Text field

Medication #4

Medication: Medication 4 name Dosage: Medication 4 dosage

Quantity: Medication 4 quantity Category: Medication 4 category

Frequency: Medication 4 frequency MD: Medication 4 md

Pill count: Medication 4 pill count Discontinued at: Medication 4 discontinued at

Adverse effects: Medication 4 notes

Since when: Text field

Medication #5

Medication: Medication 5 Name Dosage: Medication 5 Dosage

Quantity: Medication 5 Quantity Category: Medication 5 Category

Frequency: Medication 5 Frequency MD: Medication 5 MD

Pill count: Medication 5 Count Discontinued at: Medication 5 Discontinued

Adverse effects: Medication 5 Notes

Since when: Text field

 

9. What is your current employment situation? Check all that apply:

Checkboxes

If "other", please specify

Text field

10. If currently employed:
What is your occupation?

Employer: Employer 1 name 

Do you enjoy your work?

Text field

How many hours a day do you work?

Text field

Do you take work home with you?

Text field

11. How is your social interaction? Check all that apply:

Checkboxes

If "other", please specify
Text field

12. What is your current financial situation? Check all that apply:

Checkboxes
If "other", please specify:

Text field

13. What is your legal situation? Check all that apply:

Checkboxes

Please Explain Each Answer Checked
Paragraph

14. If you are on Parole or Probation, please provide the following:
Location Of Parole/Probation:

Paragraph
Parole/Probation Officer Name:

Text field
Parole/Probation Officer Phone Number:

Text field
Parole/Probation Officer Email Address:

Text field

15. Please Provide Provide Insurance Information:

Insurance Type: (Medicaid, Medicare, Private Insurance):

Text field
If Private Insurance Please Provide Details:

Provider: Client insurance provider Insurance Plan: Client insurance plan

Group ID: Client insurance group ID Policy#: Client insurance policy #

 

16. Relationship status:

Client marital status

If "other", please specify:

Text field

 

17. What is your current level of stress?

Radio buttons

 

18. Drugs Used During Lifetime

How
Often
Have You
Used The
Following
Drugs:
Primary
Drug Of
Choice
Multiple
Times
Once Never
used
Methamphetamine Checkboxes  Checkboxes  Checkboxes  Checkboxes
Opiates/Heroin  Checkboxes  Checkboxes  Checkboxes  Checkboxes
Crack/Cocaine  Checkboxes  Checkboxes  Checkboxes  Checkboxes
Barbiturates  Checkboxes  Checkboxes  Checkboxes  Checkboxes
CBD/Marijuana  Checkboxes  Checkboxes  Checkboxes  Checkboxes
Alcohol  Checkboxes  Checkboxes  Checkboxes  Checkboxes
Steroids  Checkboxes  Checkboxes  Checkboxes Checkboxes
Amphetamines  Checkboxes  Checkboxes  Checkboxes  Checkboxes
PCP  Checkboxes  Checkboxes  Checkboxes  Checkboxes
Benzodiazepines  Checkboxes  Checkboxes  Checkboxes  Checkboxes
 Kratom  Checkboxes  Checkboxes  Checkboxes  Checkboxes

 

 

19. Have You Ever Been On Any Form Of Medicated Assisted Treatments If So Check The Following Treatments You've
Used
Checkboxes

20. How Many Times Have You Been In Inpatient Treatment

Checkboxes


21. How Many Sober Livings Have You Lived In

Checkboxes


22. Why Did You Leave Your Last Sober Living

Paragraph
23. After A Full Detoxification Period How Many Times Have You Relapsed

Radio buttons

 


Participant Signature: 

First Name: Client first name

Last Name: Client last name

Signature

Date: Date

 

Staff Signature:

First Name: Text field

Last Name: Text field

 Signature

Date: Date 

 

Audit Mark: