Welcome to Hopewell Place (304)-757-8475

Admissions Form
First Name:
Middle Name:
Last Name:
Relationship to patient:
Street Address (line 1):
Street Address (line 2):
City:

State:

Zip Code:

Phone Number(s) ...

Home Phone:	(Area Code) (Number)
Best time to call:

Work Phone:	(Area Code) (Number) (Extension)
Best time to call:

Mobile Number:	(Area Code) (Number)
Best time to call:

Email Address:

How did you learn about Hopewell?

Patient Information
First Name:
Middle Name:
Last Name:

Date of Birth:

Gender:	Not SelectedMaleFemale

Street Address (line 1):
Street Address (line 2):
City:

State:

Zip Code:

Phone Number:	(Area Code) (Number)

Marital Status... Not SelectedMarriedNever Been MarriedDivorcedSeparatedWidowed

How will you be paying for your treatment? Not SelectedCashCashier's CheckMoney OrderCredit CardInsurance

Questionnaire
Primary Addiction(s)...
Name of drug:
How long have you used:	Amount:

Name of drug:
How long have you used:	Amount:

Name of drug:
How long have you used:	Amount:

Have you ever been to treatment before? SelectNoYes (if so, complete the section(s) below - please be sure to include inpatient and outpatient programs attended)

Name of program:
Type:
Dates attended:	From To (mmddyy) (mmddyy)
Did you complete treatment? SelectNoYes
Was this a 12-step program? SelectNoYes

Name of program:
Type:
Dates attended:	From To (mmddyy) (mmddyy)
Did you complete treatment? SelectNoYes
Was this a 12-step program? SelectNoYes

Name of program:
Type:
Dates attended:	From To (mmddyy) (mmddyy)
Did you complete treatment? SelectNoYes
Was this a 12-step program? SelectNoYes

Have you ever attempted to stop drinking or using? SelectNoYes If so, which of the following symptoms did you experience? (Please check all that apply)

SeizuresShakesTremorsSwellingHeadachesNauseaVomitingOther

Are you currently or have you ever seen a psychologist, psychiatrist, therapist or counselor? SelectNoYes If so, when?

If so, why?
Were you given a diagnosis? SelectNoYes If so, what was it?

Were you placed on any medication? SelectNoYes If so, what type and the amount of dosages?


Have you thought, planned or attempted suicide? SelectNoYes If so, when? Where you under the influence at the time? SelectNoYes

Have you been ill or hospitalized in the past 30 days? SelectNoYes If so, why?


Do you have any medical problems or physical pain? SelectNoYes If yes, please describe...


Are you currently taking any prescribed medications? SelectNoYes If yes, what type of medication(s)? Who prescribed the medication to you? (Doctor’s name)

Are you able to walk, feed, dress, bathe and care for yourself? SelectNoYes

Please check yes or no for the following... N/ANoYes - Do you have any legal problems from your substance use? N/ANoYes - Have you driven under the influence? N/ANoYes - Have you lost a job due to your use? N/ANoYes - Have you missed work/called in sick due to your use? N/ANoYes - Are you isolating yourself from family and friends? N/ANoYes - Is there is a history of addiction in your family? N/ANoYes - Do you have medical problems due to your use?

Admissions Form