Other people in the home

Highest level of education completed:
1 2 3 4 5 6 7 8 9 10 11 12 (grade school)

1 2 3 4 5 6 7 8+ (post high school education)

Medical information

Have you ever undergone substance abuse treatment?
Yes No

Have you ever been hospitalized in the past?
Yes No

Have you had any serious or chronic medical or physical problems?  (Please describe)

Name and address of primary care medical provider:

Are you currently on any medication?   Yes  No
If so, what type(s) and dosage(s):

In your own words, please describe briefly what the problem is that you are experiencing.

Please tell us what type of services you need. (Check all that apply.)
Career Assessment/testing Individual therapy
Couples counseling Family therapy Child issues
Group therapy
Other

Please describe some of the feelings/thoughts you are experiencing. (Check all that apply.)
Anger Depression Anxiety/panic Alcohol/drugs
Fears Crying all the time Acting out in school
Learning problems Confusion Relationship issues
Life adjustment/enhancement
Other

How long have you been feeling this way?
less than 1 month 1-3 months more than 3 months

Has anything happened recently or changed in your life that might be related to these feelings? (Check all that apply.)
Recent loss or death of close friend/family member
Change or loss in work or living situation
Other (please specify)

Have you felt this way in the past? 
Yes No

If so, when?
Childhood (0-12)
Adolescence (13-19)
Young adult (20-30)
Other

Please explain

Have you (he/she) ever been in a drug or alcohol treatment program?  If so, when?             
  Yes  No 

If so, when?  

Have you (he/she) ever been hospitalized for psychological reasons (i.e. for depression)?
  Yes  No  

If yes, for what reason?  When did this occur?

Are you (he/she) currently taking any medications for such things as anxiety, depression, ADHD, etc.? 
Yes  No  

If so, please list names and dosages.

Have you ever been charged or convicted of a crime (misdemeanor or felony)?
Yes No

How many alcoholic drinks do you (he/she) have in a typical week? Please check amount:
0-3 4-7 8-11 12-15 more than 15

Please check “Yes” or “No” for the following questions.

Do you use any street drugs or medications prescribed for someone else?
Yes No
Are you ever involved in physical fights with other people?
Yes No
Are you currently, or have you ever, been involved in the legal system?
Yes No
Has your family ever been involved with Child Protective Service?
Yes No
If you have children, have you ever lost custody of your children?
Yes No

Thank you for taking the time to fill out our application. A clinic intake coordinator will be in touch with you shortly to continue the processing of your application.