Drug Rehabilitation Admission Form PDF Details

The process of admitting someone to a drug rehabilitation program is a detailed and comprehensive one, ensuring that the individuals receive the tailored care they need. The admission form plays a crucial role in this process, gathering essential information about the individual seeking treatment. The form, exemplified by Wendy E. Smith, MA, LMHCA's Couple Intake Form, encompasses a wide array of details starting from basic personal information such as the individual's name, date of birth, contact details, and address to more specific insights including occupation, education, and religious affiliation. It probes further into the person's ethnic, racial, national, or indigenous heritage and any other self-identifications deemed important by the individual. Crucially, the form inquires about previous experiences with counseling, psychiatric care, or drug and alcohol treatment, aiming to compile a history that will inform the treatment approach. Physical health issues or disabilities are also documented, acknowledging the significant role physical health plays in recovery. The form extends to collect information on the individual's partner, living arrangements, marital status, and details about children from current or previous relationships. Familial background, covering parents' and siblings' details and any history of parental marriage beyond the first, is included to paint a comprehensive picture of the individual's social and familial context. This meticulous collection of data is foundational in crafting a personalized treatment path that addresses the unique challenges and needs of each person entering rehabilitation.

QuestionAnswer
Form NameDrug Rehabilitation Admission Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesapplication for admission into drug rehab program, intake forms for rehab senter, intake form for someone on probation entering drug rehab, to fill in blank letter of drug rehab completion

Form Preview Example

Couple Intake Form

Wendy E. Smith, MA, LMHCA

18 W. Mercer St., Seattle, WA 98119

(206)965-8749

www.wendysmithcounseling.com

Today’s date:________

Name:________________________________________Date of birth:__________Age:_______

Address:______________________________________________________________________

_____________________________________________________________________________

Phone:_____________________________

Occupation:____________________________________________________________________

Education:_____________________________________________________________________

Religious affiliation, if any:_______________________________________________________

Ethnic/ racial/ national/ indigenous heritage:__________________________________________

Other way you identify yourself that is important to you:________________________________

Have you ever received counseling, psychiatric, or drug or alcohol treatment before? Y__ N__ If yes, please explain:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Please list any physical health problems or disabilities of any kind you currently have and how long you have had them:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Name of partner:___________________________________________________________

If living together, how long? _______________ If married, how long? _______________

If there are children from this relationship, please indicate:

Name____________________ Gender____ Age____

Name____________________ Gender____ Age____

Name____________________ Gender____ Age____

Name____________________ Gender____ Age____

If previously married, please indicate:

 

 

Name of Spouse

Years Married Date Marriage Ended

Reason

_______________

__________

_________________

_____________________________

_______________

__________

_________________

_____________________________

If there are children by previous marriage or relationship, please indicate:

Name____________________ Gender____ Age____

Name____________________ Gender____ Age____

Name____________________ Gender____ Age____

Name____________________ Gender____ Age____

If any brothers and sisters, including those deceased, please indicate:

Name

Age Gender Education Occupation

Marital Status

__________

___

____

_______

_________

___________

__________

___

____

_______

_________

___________

__________

___

____

_______

_________

___________

__________

___

____

_______

_________

___________

__________

___

____

_______

_________

___________

__________

___

____

_______

_________

___________

Father’s Name____________________ Birthplace______________

Education________________________ Occupation_____________

Present Age___If deceased, when?_______

Mother’s Name____________________ Birthplace_____________

Education________________________ Occupation_____________

Present Age___If deceased, when?_______

Was either parent married more than once? Please give details:

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

Please answer each question as completely and accurately as possible. Your information will help me learn about your relationship and help me plan your treatment.

1. What are the things you like most about your relationship?

2. What do you like most about your partner?

3. What are the things you most want to change?

4.How often do you argue? What do you most often argue about?

5. Do your arguments get physical? Verbally abusive? Please detail.

6.Do you feel safe and secure with your partner? Now? In the past? Please detail.

7.In your present relationship, can you ask your partner when you need closeness and

comfort? Please detail. Please rate your level of difficulty in doing so (1 extremely easy --

– 10 extremely difficult).

8.Can you think of bonding moments in your relationship when one of you reaches out and the other responds in a way that makes you both feel emotionally connected and secure with each other? Please detail.

9.Who did you go to for comfort when you were young? Could you always count on this person/ these people for comfort? Did this person/ these people ever betray you, or were they unavailable at critical times? What did you learn about comfort and connection from this person/ these people? Please detail.

10. If no one was safe, how did you comfort yourself?

11. Did you ever turn to alcohol, drugs, sex, or material things for comfort?

12.Have there been any particularly traumatic incidents in your previous romantic relationships? Please detail.

13.Were there significant times in your current relationship when you felt your partner was not there for you. Please detail.

14.If it is hard for you to turn to and trust others, to let them close when you really need them, what do you do when life gets too big to handle or when you feel alone?

15.Name two specific things that would make you feel safer and more secure in your present relationship.

16. Anything else about your relationship you wish to share?

Client signature____________________________________________________Date________

How to Edit Drug Rehabilitation Admission Form Online for Free

You'll find nothing challenging regarding working with the new patient intake form once you start using our PDF tool. Following these easy steps, you will definitely get the prepared file in the least period feasible.

Step 1: Choose the "Get Form Here" button.

Step 2: So, you are on the file editing page. You can add information, edit present information, highlight certain words or phrases, place crosses or checks, insert images, sign the form, erase unneeded fields, etc.

The PDF document you are going to create will consist of the following sections:

writing rehab form part 1

The system will expect you to prepare the Ethnic racial national indigenous, Other way you identify yourself, Have you ever received counseling, and Please list any physical health part.

Filling in rehab form part 2

Identify the key details the section.

rehab form blanks to complete

The Name of partner, If living together how long If, If there are children from this, If previously married please, Years Married Date Marriage Ended, If there are children by previous, and Name Gender Age Name Gender Age area enables you to indicate the rights and responsibilities of either side.

stage 4 to finishing rehab form

Finish by reading the next sections and preparing them as needed: Name Gender Age Name Gender Age, If any brothers and sisters, Fathers Name Birthplace Education, and Mothers Name Birthplace Education.

rehab form Name Gender Age Name Gender Age, If any brothers and sisters, Fathers Name Birthplace Education, and Mothers Name Birthplace Education blanks to insert

Step 3: Hit the "Done" button. Next, it is possible to transfer the PDF document - save it to your device or forward it by means of electronic mail.

Step 4: To avoid different complications in the long run, you should prepare a minimum of a few duplicates of the file.

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