Pre-Admission Application

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:

Date of Birth:

Age:

Sex:

SS#:

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:

Address:

City:

County and State:

Zip:

Home Phone:

Cell Phone:

Work Phone:

REFERRAL SOURCE

How did you first hear about Seabrook House?

Other:

Name of therapist/counselor/family that referred you:

Address:

City:

County and State:

Zip:

Phone:

Cell Phone:

SOCIAL HISTORY

Current/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 USE

Date last used

How much on that date?

Average Frequency/ Average Amount

Primary substance

Secondary substance

Third substance

HEALTH INSURANCE INFORMATION (Patient is the Scubscriber)

Employer Name:

Employer Phone/Contact:

Hidden

Address:

Hidden

City:

Hidden

County and State:

Hidden

Zip:

Occupation:

How many years/months at present employer?:

PATIENT HEALTH INSURANCE

Insurance Name:

ID #:

Group #:

Please list ALL Telephone/800 #'s on your insurance ID card:

IF APPLICABLE, SECONDARY INSURANCE -

Select subscriber relationship to patient

Name of subscriber:

DOB:

SS#:

Employer (name, address, and phone):

OTHER HEALTH INSURANCE

Insurance 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:

Phone

This field is for validation purposes and should be left unchanged.

Pre-Admission Application

RESOURCES

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