PRE-ASSESMENT FORM

 

Client first nameClient last name         DOB: Client birthdate

 

Client phone       Client email

 

Gender: Dropdown

                  

How did you hear about us?  Text field

 

Client substances of choice          Date of last use: Date

 

Marital Status: Client marital status          Spouse/Family Addiction History: Paragraph

 

List Recovery Experience: Paragraph

 

List all Mental Health condtions: Paragraph

 

List Physical Health condtions: Paragraph

 

Self Harm History: Paragraph

 

List all medications: Medication

 

 

 EmploymentHistory

 

Do you have a valid ID?  Dropdown

 

Identification Number: Text field

 

Are you a Veteran? Dropdown

 

Do you have a birth certificate/social security card? Dropdown

 

Current Probation Status/Probation Officer Information: Paragraph

 

 Criminal History

List Criminal History: Paragraph

 

Are you mandated to complete a program?  Dropdown

Do you have any active warrants?  Dropdown

 

Are you a listed sex offender?  Dropdown

 

Do you have your own transportation?  Dropdown

 

What is your preferred method of payment? Dropdown

 

Signature