Patient Full Name (First, Middle & Last)
Date of Birthday
Do you have social security card?
Last 4 of Social Security Number
Do you have identification? (driver’s license, ID, passport, green card)
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)
Where are you employed?
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?
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?
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?
How many Tickets/Citations/Warrants?
12345 or more
Description of Tickets/Citations (Nature, county, etc.)
Have you ever been arrested?
How many times have you been arrested?
How many times has the arrest been alcohol/drug related?
Have you been to prison?
How many years?
Are you currently on probation or parole?
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?
What psychotropic medication(s) are you taking?
Are you compliant with taking your psychotropic medication(s)?
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.)
What is their relationship?
Have you ever been in counseling or mental health treatment before? (For example: Counselor, Psychiatrist, Psychologist, Marriage/Family Counselor)
When and Where
Please explain the reason for seeing a psychiatrist or counselor
Have you ever been hospitalized for mental and emotional problems?
Have you attempted suicide?
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)
Are you willing to receive the COVID vaccination?
Do you have your proof of vaccination card?
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
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