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Client Admission Form

Client (Patient) Information:

Funding Guarantor (if different from client):


Payment:

Source of Information (if different from client or Funding Guarantor):

Referring Professional: (if applicable)

1. Precipitating Event/Motivation


2. Medical History (Biomedical Complications)

3. Psychological History (Emotional/Behavioral)


4. Alcohol/Drug History

Complete for alcohol or any other addictive substances you have used (including nicotine) in the past 6 months.

5. Treatment History

6. Family

Family Program Participation


7. Employment Status


8. Legal History

9. Nutrition

10. Recovery