Patient Full Name (First, Middle & Last)
Date of Birthday
Sex M F
Marital Status M D S
Do you have social security card? Yes No
Last 4 of Social Security Number
Do you have identification? (driver’s license, ID, passport, green card) Yes No Your Phone Number Emergency Contact Name and Relationship Emergency Contact Phone Number
Next Are you a Veteran? Yes No Are you currently enrolled in school? Yes No
What school do you attend?
Are you currently employed? (Please note that employment is restricted for clients for the first 4 months) Yes No
Where are you employed?
Are you a sexual offender? (Due to our proximity to a school, we are required to ask this questions) Yes No 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?
Back Next Have you been in treatment before? Yes No
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
Back Next When was the last time you used? What drugs? How old were you when you started using drugs? How old were you when you started drinking alcohol? How often do you use drugs? How often do you drink alcohol? Have you used any of the following drugs? (Please check all that apply.) Alcohol Marijuana Heroin Bath Salts Cocaine Amphetamine Meth Club Drugs PCP LSD Inhalants Prescription K2/Spice Steroids Ecstasy/Molly Do you use alcohol or drugs to get started in the morning? Yes No
if yes explain
Has your physician ever told you to cut down or stop using alcohol/drugs? Yes No
if yes explain
Has the use alcohol/drugs caused you to be late to or miss work? Yes No
if yes explain
Has the use of alcohol/drugs affected your home life or relationship? How do you feel about your use of alcohol/drugs?
Back Next Do you have any Tickets/Citations/Warrants? Yes No
How many Tickets/Citations/Warrants? 1 2 3 4 5 or more Description of Tickets/Citations (Nature, county, etc.)
Have you ever been arrested? Yes No
How many times have you been arrested? How many times has the arrest been alcohol/drug related?
Have you been to prison? Yes No
How many years?
Are you currently on probation or parole? Yes No How long is your sentence? What is your probation/parole officer name and telephone number?
Back Next Do you have a mental health diagnosis? Yes No
Please select all that apply Depression Bipolar Mania Schizophrenia Anxiety Drug or Alcohol Other
Are you currently being treated? Yes No
What psychotropic medication(s) are you taking? Are you compliant with taking your psychotropic medication(s)?
Do you hear any voices? Yes No Do the voices tell you to do violent things to yourself or others? Yes No 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.) Yes No
What is their relationship?
Have you ever been in counseling or mental health treatment before? (For example: Counselor, Psychiatrist, Psychologist, Marriage/Family Counselor) Yes No
When and Where Please explain the reason for seeing a psychiatrist or counselor
Have you ever been hospitalized for mental and emotional problems? Yes No Have you attempted suicide? Yes No
Date of last attempt
Check any of the following symptoms that you’ve experienced in the last 30 days Change in appetite Excessive drinking Anger management Problems with drug use Weight gain/loss Fatigue/lack of energy Panic attacks Anxiety Loneliness Nightmares Memory problems Sexual abuse Sexual desire Mood swings Hallucinations Low self-esteem Self-mutilation Difficulty concentrating Confusion Flashbacks Depression Headaches Sleep disturbance/insomnia Guilt Paranoia Delusions Fears/phobia Violence Compulsive behaviors Hyperactivity poor impulse control Please list other symptoms not listed above:
Back Next Primary Care Physician Date of Last Medical Exam Do you have any terminal illnesses or physical limitations? Yes No
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) Yes No
Are you willing to receive the COVID vaccination? Yes No
Do you have your proof of vaccination card? Yes No
Back Next Our primary care is a six-month program for people with drug and alcohol addiction and emphasizes discipleship. Are you willing to submit to the program of recovery? Yes No The cost if $500 a month. Are you able to pay this? Yes No Back 
