Pre - Admission Assesment
Personal And Financial Information
Full Name
Your answer
Address
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State and Zip Code
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County
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Phone Number *
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Social Security Number
Your answer
Date of Birth
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DD
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Currently Employed
Employer
if not employed answer is "none"
Your answer
Is your job in jeopardy
Personal Monthly Income
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Total Household Income
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Number of People in Household
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Do You Have Medical Insurance
If so, please list the insurance carrier
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Group Number
Your answer
Contract Number
Your answer
Customer Service Number - Listed on the back of your insurance card
Your answer
Suspended
Do You Have A Current Picture ID *
Photo ID is required for admission
Do You Have A Social Security Card
Do You Take Prescription Medications
If So, Please List All Medications You Are Currently Taking
Prescription and not Prescribed drugs
Your answer
Do You Take Your Medicines as Prescribed
What Are Your Current Medical Conditions, If Any:
If yes to any Current Medical Conditions Please explain
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Why Are You Seeking Treatment Today?
Your answer
What Substances Do You Currently Use?
Please describe any and all substances abused
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What Is Your Drug of Choice
Please describe any and all substances abused
Your answer
What Was Your Age of First Use
Your answer
How Often Do You Use Your DOC
Your answer
How Much Of Your DOC Do You Use?
Your answer
When Was The Last Time You Used Drugs Of Any Kind?
Your answer
How Do You Use Drugs?
Do You Have A History of Blackouts
Do You Have A History of Seizures
Do You Have A History Of Withdrawal Symptoms? If So, Please Describe These Symptoms
Your answer
Have You Ever Had Any Of The Following?
Have You Had Suicidal Thoughts In Your Past?
Have You Ever Attempted Suicide?
If Yes, How Many Times Have You Attempted Suicide?
Your answer
Date of Last Suicide Attempt
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DD
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YYYY
Do You Have Current Thoughts Of Suicide? - If You Are Having Current Suicidal Thoughts Please Call 662-234-7521, 911, Or Go To Your Local Emergency Room
Do You Have A Suicide Plan
Have You Ever Been to Treatment Before?
If So, How Many Times?
Your answer
Date of Last Treatment
MM
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DD
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Type of Treatment
Have You Ever Attended AA or NA?
Do You Have A Sponsor?
What Is Your Longest Period of Sobriety?
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What Are Some Of The Main Consequences Of Your Use?
Your answer
Do You Have Any Current Legal Issues?
Your answer
If You Have Current Legal Issues, What Is The Charge?
Your answer
Do you Have a Probation Officer?
Marital Status
Your answer
Does Your Spouse Use?
Is Your Spouse Supportive?
Who Do You Live With?
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Do You Have Children?
How many Children and Their Age?
Your answer
Who is Caring for the Children Now?
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Is DHS Involved?
Does anyone in the home use drugs?
Was an Ultimatum Given?
By whom?
Your answer
Highest Level of Education Completed
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What Date Would You Like To Come To Treatment?
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