Drug rehabilitation admission form is a necessary step in the rehabilitation process. The form helps to ensure that all of the necessary information is gathered upfront, which can help to make the admission process smoother. The form can be used by both individuals seeking treatment and their families. It is important to understand what is involved in the drug rehab admission process before you begin treatment. The purpose of this blog post is to provide an overview of the drug rehab admission form and what it entails. We will discuss why the form is important and what information it collects. We will also provide tips for completing the form accurately. If you are considering drug rehabilitation, or if you are a family member of someone who needs treatment, this post will be helpful to you.
This knowledge will aid you to comprehend better the details of the drug rehabilitation admission form before you start filling it out.
| Question | Answer |
|---|---|
| Form Name | Drug Rehabilitation Admission Form |
| Form Length | 10 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 2 min 30 sec |
| Other names | new patient intake form, inpatient recovery intake forms, intake form for someone on probation entering drug rehab, rehab paperwork |
Couple Intake Form
Wendy E. Smith, MA, LMHCA
18 W. Mercer St., Seattle, WA 98119
(206)
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:
______________________________________________________________________________
______________________________________________________________________________
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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: |
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Name of Spouse |
Years Married Date Marriage Ended |
Reason |
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__________ |
_________________ |
_____________________________ |
_______________ |
__________ |
_________________ |
_____________________________ |
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 |
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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________