Admissions Form

General Admissions Information

Person Completing Form*

Desired Admission Date*

Your relationship to the individual

Email*

Preferred Phone Number*

Patient Demographic Information

First Name

Last Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth

Age

Gender

Marital Status

SSN

Phone

Emergency Contact Name

First Last

Emergency Contact Phone

Relationship to Patient

Second Emergency Contact Name

First Last

Second Emergency Contact Phone

Relationship to Patient

Referral Information

Referred by*

Organization (if known)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office Number

Fax Number

Children/Adolescent Only

Legal/Primary Custodian

Mother's Name

Mother's Employer

Mother's Occupation

Mother's Address

Mother's Phone Number

Mother's Email

Father's Name

Father's Employer

Father's Occupation

Father's Address

Father's Phone Number

Father's Email

Presenting Problems/Treatment History

List Primary Issues

Current Diagnosis

Current Medications (list dosages and compliance)

Substance Use (include date of last use and amount)

Outpatient Providers Treatment (include dates of treatment, IOP, PHP, and group therapy)

Inpatient Providers Treatment (include dates of treatment, detox, acute and residential)

Significant Medical Issues (include allergies and special needs)

Legal Issues (include probation, court dates, etc)

Primary Insurance Information

Insurance Company Name

Subscriber Name

Subscriber SSN

Subscriber DOB

Subscriber ID

Group Number

Employer

Phone Number

Secondary Insurance Information