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:

Social Security Number:

- -

Date of Birth:

Gender:

Male Female

Street Address (line 1):

Street Address (line 2):

City:

State:

Zip Code:

Phone Number:

(Area Code) (Number)

Marital Status...

Never been married Married Divorced Separated Widowed

How will you be paying for your treatment?

Cash Cashier’s Check Money Order Credit Card Insurance

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? No Yes

(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? No Yes

Was this a 12-step program? No Yes

Name of program:

Type:

Dates attended:

From To
(mmddyy) (mmddyy)

Did you complete treatment? No Yes

Was this a 12-step program? No Yes

Name of program:

Type:

Dates attended:

From To
(mmddyy) (mmddyy)

Did you complete treatment? No Yes

Was this a 12-step program? No Yes

Have you ever attempted to stop drinking or using? No Yes

If so, which of the following symptoms did you experience? (Please check all that apply)

Seizures	Shakes	Tremors	Swelling
Headaches	Nausea	Vomiting	Other... describe:

Are you currently or have you ever seen a
psychologist, psychiatrist, therapist or counselor? No Yes

If so, when?

If so, why?

Were you given a diagnosis? No Yes

If so, what was it?

Were you placed on any medication? No Yes

If so, what type and the amount of dosages?

Have you thought, planned or attempted suicide? No Yes

If so, when?

Where you under the influence at the time? No Yes

Have you been ill or hospitalized in the past 30 days? No Yes

If so, why?

Do you have any medical problems or physical pain? No Yes

If yes, please describe...

Are you currently taking any prescribed medications? No Yes

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? No Yes

Please check yes or no for the following...

No    Yes   -  Do you have any legal problems from your substance use?
No    Yes   -  Have you driven under the influence?
No    Yes   -  Have you lost a job due to your use?
No    Yes   -  Have you missed work/called in sick due to your use?
No    Yes   -  Are you isolating yourself from family and friends?
No    Yes   -  Is there is a history of addiction in your family?
No    Yes   -  Do you have medical problems due to your use?