Pre-Admission Application

[vc_row class=”title_arrow” id=”title_arrow”][vc_column][/vc_column][/vc_row][vc_row class=”content_pad title_after”][vc_column][vc_column_text align=”left” class=”para black”][/vc_column_text][/vc_column][/vc_row][vc_row class=”admission-application_form”][vc_column]

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:
This field is hidden when viewing the form
Address:
This field is hidden when viewing the form
City:
This field is hidden when viewing the form
County and State:
This field is hidden when viewing the form
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.

[/vc_column][/vc_row][vc_row class=”content_pad title_after”][vc_column][vc_column_text align=”left” class=”para black”][/vc_column_text][/vc_column][/vc_row]

Pre-Admission Application

RESOURCES

SUBSCRIBE