Patient Full Name (First, Middle & Last)
Do you have social security card?
Do you have identification? (driver’s license, ID, passport, green card)
Your Phone Number
Emergency Contact Name and Relationship
Emergency Contact Phone Number
Are you currently employed? (Please note that employment is restricted for clients for the first 4 months)
Are you a sexual offender? (Due to our proximity to a school, we are required to ask this questions)
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?
Has your physician ever told you to cut down or stop using alcohol/drugs?
Has the use alcohol/drugs caused you to be late to or miss work?
Has the use of alcohol/drugs affected your home life or relationship?
How do you feel about your use of alcohol/drugs?
Have you ever been arrested?
Have you been to prison?
Are you currently on probation or parole?
How long is your sentence?
What is your probation/parole officer name and telephone number?
Are you currently being treated?
Do you hear any voices?
Do the voices tell you to do violent things to yourself or others?
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.)
Have you ever been in counseling or mental health treatment before? (For example: Counselor, Psychiatrist, Psychologist, Marriage/Family Counselor)
Have you ever been hospitalized for mental and emotional problems?
Have you attempted suicide?
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:
Have you received a COVID vaccination? (All staff and clients are required to be fully vaccinated)
ARM Dallas is devoted to healing those struggling with addiction, mental health disorders, and dual diagnosis through faith-based treatment and unwavering support.
What We Treat
1128 Reverend CBT Smith St, Dallas, TX 75203
©2021 Copyright ARM Dallas All Rights Reserved