Patient Full Name (First, Middle & Last)
Date of Birthday
Sex MF
Marital Status MDS
Do you have social security card? YesNo
Last 4 of Social Security Number
Do you have identification? (driver’s license, ID, passport, green card) YesNo Your Phone Number Emergency Contact Name and Relationship Emergency Contact Phone Number
What school do you attend?
Are you currently employed? (Please note that employment is restricted for clients for the first 4 months) YesNo
Where are you employed?
Are you a sexual offender? (Due to our proximity to a school, we are required to ask this questions) YesNo How did you hear about ARM? What led you to come here today? If accepted what are your expectations of this treatment center? What is your personal expectation of yourself?
Give the name of the Treatment Centers, Length of stay and Dates you were there. How long did you stay sober after leaving each treatment center? Give the reasons of each relapse
if yes explain
Has your physician ever told you to cut down or stop using alcohol/drugs? YesNo
Has the use alcohol/drugs caused you to be late to or miss work? YesNo
Has the use of alcohol/drugs affected your home life or relationship? How do you feel about your use of alcohol/drugs?
How many Tickets/Citations/Warrants? 12345 or more Description of Tickets/Citations (Nature, county, etc.)
Have you ever been arrested? YesNo
How many times have you been arrested? How many times has the arrest been alcohol/drug related?
Have you been to prison? YesNo
How many years?
Are you currently on probation or parole? YesNo How long is your sentence? What is your probation/parole officer name and telephone number?
Please select all that apply DepressionBipolarManiaSchizophreniaAnxietyDrug or AlcoholOther
Are you currently being treated? YesNo
What psychotropic medication(s) are you taking? Are you compliant with taking your psychotropic medication(s)?
Do you hear any voices? YesNo Do the voices tell you to do violent things to yourself or others? YesNo What are the voices saying Has anyone in your family had mental, or emotional problems? (For example: depression, suicide, mania, schizophrenia, anxiety, drug, or alcohol, etc.) YesNo
What is their relationship?
Have you ever been in counseling or mental health treatment before? (For example: Counselor, Psychiatrist, Psychologist, Marriage/Family Counselor) YesNo
When and Where Please explain the reason for seeing a psychiatrist or counselor
Have you ever been hospitalized for mental and emotional problems? YesNo Have you attempted suicide? YesNo
Date of last attempt
Check any of the following symptoms that you’ve experienced in the last 30 days Change in appetiteExcessive drinkingAnger managementProblems with drug useWeight gain/lossFatigue/lack of energyPanic attacksAnxietyLonelinessNightmaresMemory problemsSexual abuseSexual desireMood swingsHallucinationsLow self-esteemSelf-mutilationDifficulty concentratingConfusionFlashbacksDepressionHeadachesSleep disturbance/insomniaGuiltParanoiaDelusionsFears/phobiaViolenceCompulsive behaviorsHyperactivity poor impulse control Please list other symptoms not listed above:
List any medical problems that you are currently experiencing List any medications you are currently taking Name of physician monitoring these conditions Please state the reasons why you are taking each medication Who prescribed the medication?
Have you received a COVID vaccination? (All staff and clients are required to be fully vaccinated) YesNo
Are you willing to receive the COVID vaccination? YesNo
Do you have your proof of vaccination card? YesNo