Alchemy Consultion - Screening Application 

 

Caller Information: 

Caller Name: Contact 10 name

Caller relationship to client:Contact 10 type

Caller City:Text field

Caller Primary Phone:Contact 10 phone

Caller State: Text field

Caller Email: Contact 10 email

 

Referral information: 

Referred by Account name: Client Referred By

Referral source: Client Referred By

Referred by type: Text field

Referred by notes: Text field

Referred to notes: Text field

 

 

Concerned Loved Ones Contact: 

1 CLO: Name Contact 1 name
CLO: Age Text field
CLO: Phone Contact 1 phone
CLO: Email Contact 1 email
CLO: Relationship to ILO : Contact 1 type

2 CLO: Name Contact 2 name
CLO: Age Text field
CLO: Phone Contact 2 phone
CLO: Email Contact 2 email
CLO: Relationship to ILO : Contact 2 type

3 CLO: Name Contact 3 name
CLO: Age Text field
CLO: Phone Contact 3 phone
CLO: Email Contact 3 email
CLO: Relationship to ILO : Contact 3 type

4 CLO: Name Contact 4 name
CLO: Age Text field
CLO: Phone Contact 4 phone
CLO: Email Contact 4 email
CLO: Relationship to ILO : Contact 4 type

5 CLO: Name Contact 5 name
CLO: Age Text field
CLO: Phone Contact 5 phone
CLO: Email Contact 5 email
CLO: Relationship to ILO : Contact 5 type

6 CLO: Name Contact 6 name
CLO: Age Text field
CLO: Phone Contact 6 phone
CLO: Email Contact 6 email
CLO: Relationship to ILO : Contact 6 type

7 CLO: Name Contact 7 name
CLO: Age Text field
CLO: Phone Contact 7 phone
CLO: Email Contact 7 email
CLO: Relationship to ILO : Contact 7 type

8 CLO: Name Contact 8 name
CLO: Age Text field
CLO: Phone Contact 8 phone
CLO: Email Contact 8 email
CLO: Relationship to ILO : Contact 8 type

9 CLO: Name Contact 9 name
CLO: Age Text field
CLO: Phone Contact 9 phone
CLO: Email Contact 9 email
CLO: Relationship to ILO : Contact 9 type

10 CLO: Name Contact 10 name
CLO: Age Text field
CLO: Phone Contact 10 phone
CLO: Email Contact 10 email
CLO: Relationship to ILO : Contact 10 type

 

Financial Responsible party:

FRP: Relation to Client Text field

 

FRP: Email Text field

FRP: Home Phone Text field

FRP: Mobile Text field

 

Insurance Information: 

Insurance Company Provider: Client insurance provider Insurance Plan: Client insurance plan

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

Primary insurance Phone: Text field

Client Relationship to Subscriber: Text field

Subscriber First Name: Text field

Subscriber Last Name: Text field

Subscriber DOB: Text field

Subscriber SSN: Text field

Subscriber Phone: Text field

Subscriber Street: Text field

Subscriber City: Text field

Subscriber State: Text field

Subscriber Zip Code: Text field

 

Client-Identified Loved One

First Name: Client first name 

Middle Name: Client middle name 

Last Name: Client last name

Address: Client Address

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

Email: Client email 

Phone Number: Client phone

Fax: Text field

SSN: Text field

Sexual Orientation: Text field

Valid id for travel: Text field

Gender: Client gender Birthdate: Client birthdate

School: Client school

Marital status: Client marital status

Race: Client race

Current support system: Text field

Living arrangement notes: Text field

Access to weapons?: Text field

 

Any children at home?: Text field

 

Current Treatment Providers

 

TreatmentCenterHistory

Psychiatrist: Text field

Therapist: Text field

Psychologist: Text field

Treatment Provider: Psychologist Text field

Treatment Provider: Internist Text field

 

Presenting Issues

Why are you seeking Intervention:

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Primary Presenting Issue:

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Secondary Presenting Issue:

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Presenting Issues Notes:

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Checkboxes

 

Substance Abuse History 

Do they have any
substance abuse
issues?:

Text field

Longest clean/sober
time?:

Paragraph

Describe the
progression of drug
use?:

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Family history of SA
notes:

Paragraph

When was their
longest clean/sober
time?:

Paragraph

What led to their
relapse?:

Paragraph

1 Drug of Choice
Route: Text field

Duration: Text field

Amount Last use :Text field

Frequency of UseText field

Age of first use:Text field

2 Drug of Choice
Route:Text field

Duration: Text field

Amount Last use :Text field

Frequency of UseText field

Age of first use:Text field

3 Drug of Choice
Route: Text field

Duration: Text field

Amount Last use :Text field

Frequency of UseText field

Age of first use:Text field

4 Drug of Choice
Route: Text field

Duration: Text field

Amount Last use:Text field

Frequency of Use: Text field

Age of first use:Text field

Substance of Choice (choose all that apply): Client substances of choice

 

Sexual Acting Out/ Offensive Behavior 

Sexual Acting Out/ Offensive Notes

Paragraph

 

ED History

Do you think they have an eating disorder

Checkboxes

If yes, Continue:

Body image issues during adolescence:

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Describe what do they normally eat in a day: 

Paragraph

How do they feel about their body:

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Substance used to control weight:

Paragraph

Exercise Amounts:

Paragraph

What foods do they binge on?:

Paragraph

Duration of Eating Disorder:

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Frequency of binging episodes:

Paragraph

Frequency of purging episodes:

Paragraph

Date of last purge:

Paragraph

Date of last binge:

Paragraph

ED comments:

Paragraph

Current Height (ft): Text field

Current Height (inch): Text field

Current Weight: Text field

BMI: Text field

Highest Weight: Text field

Lowest Weight: Text field

When was your highest weight: Text field

Treatment History: 

Treatment Provider 1: Text field

Provider Type: Text field

Phone: Text field

Email: Text field

Treatment Provider 2: Text field

Provider Type: Text field

Phone: Text field

Email: Text field

Treatment Provider 3: Text field

Provider Type: Text field

Phone: Text field

Email: Text field

Treatment Provider 4: Text field

Provider Type: Text field

Phone: Text field

Email: Text field

 

What was treated?: 

Paragraph

Admitted: Treatment center 2 started Discharged: Treatment center 2 ended

Level of Care: Text field

Treatment history Notes: Treatment center 2 notes

12 Step Programs Tried: Text field

Treatment Center #2

Treatment Provider: Treatment center 3 name

What was treated?: 

Paragraph

Admitted: Treatment center 3 started Discharged: Treatment center 3 ended

Level of Care: Text field

Treatment history Notes: Treatment center 3 notes

12 Step Programs Tried: Text field

Treatment Center #3

Treatment Provider: Treatment center 4 name

What was treated?: 

Paragraph

Admitted: Treatment center 4 started Discharged: Treatment center 4 ended

Level of Care: Text field

Treatment history Notes: Treatment center 4 notes

12 Step Programs Tried: Text field

Treatment Center #4

Treatment Provider: Treatment center 5 name

What was treated?: 

Paragraph

Admitted: Treatment center 5 started Discharged: Treatment center 5 ended

Level of Care: Text field

Treatment history Notes: Treatment center 5 notes

12 Step Programs Tried: Text field

 

Psych/Co-Occurring Disorders: Mental Health Notes

Diagnosed Mental
Health Issues:

Paragraph

Self Diagnosed
Mental Health Issues:

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HX of Self Harm or
HX of Violence:

Paragraph

History of Suicide
Attempt(s):

Paragraph

Checkboxes

 

 

Pattern of Homicidal
Thoughts:

Text field

 

 

Have they
experienced
hallucinations?:

Text field

Have they ever heard
voices?:

Text field

When was this?:

Text field

 

Were they under the
influence?:

Text field

Ever been treated for
these issues?:

Text field

 

 

Trauma Issues : Description of Trauma

Checkboxes

How recent was the event?: Text field

Ever diagnosed with PTSD: 

Paragraph

Current flashbacks/nightmares?: 

Paragraph

 

Medical Information: Medical Conditions

Diagnosis: Client diagnosis 

Related Special
Needs

Hospitalization for
Medical Condition

History of Surgeries

Vision Problems

Food Allergies Notes:

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Medical Allergies: Client allergies

Medical Allergy notes: 

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Health problems: Client health problems

Special diet: Text field

Checkboxes

Any history of
hypertension: Text field

Do you have
Diabetes/ insulin
dependent?: Text field

Checkboxes

Tremors: Text field

Checkboxes

Have you
experienced
seizures?: Text field

Been diagnosed with
seizure disorder?: Text field

Using Rx to treat
seizures? What Rx?:Text field

When was last
seizure?: Text field

Were you under the
influence?: Text field

Stomach or
Esophageal
Problems: Text field

Infectious Disease(s): Text field

 

Medications

Medication

 

 

Legal Issues**

Pending Legal Issues:

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Client currently on parole or probation: Text field

Legal isssues due to use/behavior:

Paragraph

Client permission to leave state?: Text field

Next court date: Text field

Legal History Notes:

Paragraph