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. Goals for loved one while in Care Mangement
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8. How will loved one benefit from Care Management
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9. Why are you reaching out
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10. What is the name of your loved one that we are intervening on
Client first name Client last name
11. Does your loved one have a nickname
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12. What is your loved one's date of birth
Client birthdate
13. What gender does your loved one identify as
Client gender
14. What is your loved one's home address
Client Address
15. Who does your loved one live with
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16. Does your loved one have children
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17. What is your loved one's sexual orientation
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18. What is your loved one's marital status
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19. Does anyone else in your family struggle with substance abuse
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20. Tell us about your loved one's support system
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21. Is your loved one abusing drugs
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22. Does your loved one have a mental health diagnosis
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23. If there is no mental health diagnosis, do you have any concerns or suspicions about their mental health
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24. What have you experienced that has you concerned
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25. Has your loved one experienced hallucinations
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26. Has your loved one ever heard voices
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27. Has your loved one ever believed that they were being spied on or followed
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28. Does your loved one have a history of violence toward others
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29. Does your loved one have any formal fight training such as martial arts or boxing
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30. Does your loved one own a gun
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31. Has your loved one ever been arrested
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32. Does your loved one have a history of self harm (example: cutting, burning, pulling out hair)
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33. Has your loved one ever attempted to take their own life
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34. Does your loved one ever have thoughts or made statements about taking their own life
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35. Has your loved one ever made statements about harming someone else
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36. Has your loved one experienced trauma
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37. Has your loved one ever struggled with an eating disorder
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38. Has your loved one ever used substance to control their weight
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39. Has your loved one ever been hospitalized with an eating disorder
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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. Has your loved one ever experienced a stroke
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44. Has your loved one ever suffered from a head injury where they lost conciousness
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45. Has your loved one ever experienced seizures or convulsions
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46. Please list any surgeries your loved one has had over the last 5 years
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47. Has your loved one been hospitalized in the last 6 months for a medical condition
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48. When was the last time your loved one saw a physician
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49. Is your loved one taking any over the counter medication
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50. Is your loved one taking any prescribed medication
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51. Is there any medication that your loved one has been prescribed but refuses to take? Please tell us what medication your loved one should be taking and why they are refusing to take it
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52. Has your loved one ever been to treatment before
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53. Name of your loved one's psychiatrist
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54. Phone or Email
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55. Name of your loved one's psychologist
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56. Phone or Email
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57. Name of your loved one's therapist
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58. Phone or Email
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59. Name of your loved one's Internist
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60. Phone or Email
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61. Is there anything you would like us to know about your loved one's current treatment provider
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62. Does your loved one have a valid ID
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63. Is your loved one currently employed
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64. Where does your loved one work
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65. Name of the financially responsible party
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66. Phone Number
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67. Email address
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68. Address
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69. Loved one's relationship to the financially responsible party
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