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/codeineultracetultramvaliumvicodinWETzoloftxanax Secondary 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/codeineultracetultramvaliumvicodinWETzoloftxanax Third 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/codeineultracetultramvaliumvicodinWETzoloftxanax HEALTH INSURANCE INFORMATION (Patient is the Scubscriber)Employer Name: Employer Phone/Contact: HiddenAddress: HiddenCity: HiddenCounty and State: HiddenZip: 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: PhoneThis field is for validation purposes and should be left unchanged.
