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