Addiction Intake Forms Details

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.

QuestionAnswer
Form NameDrug Rehabilitation Admission Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesnew patient intake form, inpatient recovery intake forms, intake form for someone on probation entering drug rehab, rehab paperwork

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:

______________________________________________________________________________

______________________________________________________________________________

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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:

 

 

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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Fathers Name____________________ Birthplace______________

Education________________________ Occupation_____________

Present Age___If deceased, when?_______

Mothers Name____________________ Birthplace_____________

Education________________________ Occupation_____________

Present Age___If deceased, when?_______

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

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

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______________________________________________________________________________

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________