Is this form being completed as part of a family/employer intervention? Yes No If YES, please provide name, relationship to prospective patient, phone number, and e-mail address of person completing this intake:Patient's Legal Name:Nick Name:Home Phone:Cell Phone:Home Address:Work Phone:City:County and State:Zip:Email* Present Marital Status:SingleMarriedDivorcedLiving as MarriedSignificant Other/Life PartnerSeperatedWidow/WidowerDate of Birth:Age:Sex:MaleFemaleSS#:How many people live in your home including you?:Dependent Children/Step (Names/Ages):Emergency Contact Name/Next of Kin:Emergency Contact Email Address: Relationship:MotherFatherWifeHusbandSignificant OtherSonDaughterSisterBrotherLife partnerAuntUncleCousinNephewNieceGrandmotherGrandfatherFriendOtherAddress:City:County and State:Zip:Home Phone:Cell Phone:Work Phone:REFERRAL SOURCEHow did you first hear about Seabrook House?*--Please Select--PhonebookBillboardNewspaper AdMagazine AdSeminar/ConferenceInternet Search EngineLocal ResidentPrimary DoctorCounselor/TherapistAlumni/Former PatientTV CommercialInsurance CompanyMobile AdRadio AdTrain Station AdBus AdOtherOther:Name of therapist/counselor/family that referred you:Address:City:County and State:Zip:Phone:Cell Phone:SOCIAL HISTORYCurrent/past legal problems (DWI?- when?):Current health (high BP, ulcers, diabetes, allergies, etc.):Lawyer name and phone number:Primary doctor name and phone number:Current medications (name/dosage, amount/why prescribed):Present/past alcohol/drug/pyschiatric treatment or hospitalization in past 5 years:Dates:How many days?Did you complete?Present/past alcohol/drug/pyschiatric treatment or hospitalization in past 5 years:Dates:How many days?Did you complete? No Yes Present/past alcohol/drug/pyschiatric treatment or hospitalization in past 5 years:Dates:How many days?Did you complete? No Yes Present/past alcohol/drug/pyschiatric treatment or hospitalization in past 5 years:Dates:How many days?Did you complete? No Yes ALCOHOL/DRUG USEDate last usedHow much on that date?Average Frequency/ Average AmountPrimary substancealcoholacidalcohol beeralcohol bourbonalcohol ginalcohol rumalcohol scotchalcohol vodkaalcohol whiskeyalcohol winealcohol brandyalcohol crown royalalcohol hennesseyalcohol malt liquoralcohol mouthwashalcohol rubbingalcohol southern comfortalcohol tequilaalprazolamambienamphetaminesativanbenadrylbuprenexbuprenorphinechewing tobaccococainecrack cocainedarvacetdarvondilaudedduragesic patchecstasyfentanylfiornalfiorocetGHBhashishheroinehydrocodoneinhalantketamineketamine-special KklonopinlibriumloratablorazepamLSDmarijuanamethadonemethadone-clinicmethadone-streetmethamphetaminemorphinemushroomsnicotinenicotine-cigarettesnicotine-cigarsoxycodoneoxycodone IRoxycontinPCPpercodanpercosetprozacritalinroxycodonesomasuboxonetorbitoltrazadonetylenol 3tylenol w/codeineultracetultramvaliumvicodinWETzoloftxanaxSecondary substancealcoholacidalcohol beeralcohol bourbonalcohol ginalcohol rumalcohol scotchalcohol vodkaalcohol whiskeyalcohol winealcohol brandyalcohol crown royalalcohol hennesseyalcohol malt liquoralcohol mouthwashalcohol rubbingalcohol southern comfortalcohol tequilaalprazolamambienamphetaminesativanbenadrylbuprenexbuprenorphinechewing tobaccococainecrack cocainedarvacetdarvondilaudedduragesic patchecstasyfentanylfiornalfiorocetGHBhashishheroinehydrocodoneinhalantketamineketamine-special KklonopinlibriumloratablorazepamLSDmarijuanamethadonemethadone-clinicmethadone-streetmethamphetaminemorphinemushroomsnicotinenicotine-cigarettesnicotine-cigarsoxycodoneoxycodone IRoxycontinPCPpercodanpercosetprozacritalinroxycodonesomasuboxonetorbitoltrazadonetylenol 3tylenol w/codeineultracetultramvaliumvicodinWETzoloftxanaxThird substancealcoholacidalcohol beeralcohol bourbonalcohol ginalcohol rumalcohol scotchalcohol vodkaalcohol whiskeyalcohol winealcohol brandyalcohol crown royalalcohol hennesseyalcohol malt liquoralcohol mouthwashalcohol rubbingalcohol southern comfortalcohol tequilaalprazolamambienamphetaminesativanbenadrylbuprenexbuprenorphinechewing tobaccococainecrack cocainedarvacetdarvondilaudedduragesic patchecstasyfentanylfiornalfiorocetGHBhashishheroinehydrocodoneinhalantketamineketamine-special KklonopinlibriumloratablorazepamLSDmarijuanamethadonemethadone-clinicmethadone-streetmethamphetaminemorphinemushroomsnicotinenicotine-cigarettesnicotine-cigarsoxycodoneoxycodone IRoxycontinPCPpercodanpercosetprozacritalinroxycodonesomasuboxonetorbitoltrazadonetylenol 3tylenol w/codeineultracetultramvaliumvicodinWETzoloftxanaxHEALTH INSURANCE INFORMATION (Patient is the Scubscriber)Employer Name:Employer Phone/Contact:This field is hidden when viewing the formAddress:This field is hidden when viewing the formCity:This field is hidden when viewing the formCounty and State:This field is hidden when viewing the formZip:Occupation:How many years/months at present employer?:PATIENT HEALTH INSURANCEInsurance Name:ID #:Group #:Please list ALL Telephone/800 #'s on your insurance ID card:IF APPLICABLE, SECONDARY INSURANCE -Select subscriber relationship to patientMotherFatherWifeHusbandSignificant OtherSonDaughterSisterBrotherLife partnerAuntUncleCousinNephewNieceGrandmotherGrandfatherFriendOtherName of subscriber:DOB:SS#:Employer (name, address, and phone):OTHER HEALTH INSURANCEInsurance Name:ID #:Group #:Please list ALL Telephone/800 #'s on your insurance ID card:Any comments/questions from person completing this form:Email address of person completing this form:EmailThis field is for validation purposes and should be left unchanged.
