Recovery House Admission Screening Form

Applying For:*

Wilson HouseBills HouseDean’s house
Date of Application*

MonthDayYear
Date
Requested Date of Admission*

MonthDayYear
Date
DEMOGRAPHICS
Name*
DOB*
Cell Phone*
Email Address*
example@example.com
Social Security Number*
Present Address*
Relationship Status*
Emergency Contact Name*
Emergency Contact Phone Number*

Area CodePhone Number
Are you Employed*

YesNo
If yes, list name of employer, hourly rate and number of hours worked weekly
Other Source of Income*
SUBSTANCE USE HISTORY
Substance of Choice and Method*
Sobriety Date*

MonthDayYear
Date
MEDICAL INFORMATION
Medical Insurance Name and Number*
Medical Conditions*
Medication (list all medication, dosage & frequency)*
Primary Care Doctor Name, Address & Phone Number*
BEHAVIORAL HEALTH
Provide name, agency affiliation, phone, and frequency of services for all noted below.
Individual Therapist*
Psychiatrist/APRN*
Case Manager*
Other*
Diagnosis*
Legal History
Have you ever been arrested?*

YesNo
If Yes, provide details
Parole/Probation Officer Name & Phone Number*
Please Note:
A signed Resident Handbook and Release of Information’s for all noted individuals above will be required on or at the time of admission.

A copy of your insurance card will be required upon admission.

Any resident taking a controlled substance will be required to provide a combination lock box for storage and consent to administration by Staff Mates
Should be Empty:

Legal History