Seabrook House Addiction

Pre-Admission Intake Form

Please complete the PDF form below and click SUBMIT.
For your security, this form will be encrypted during transmission to our web site.

[ What to Expect ]	[ Stabilization ]	[ Patient Rights ]	[ Patient Policy ]
[ Family Visitation ]	[ What to Bring ]	[ Pre-Admission Intake ]	[ Fees ]

Is this form being completed as part of a family/employer intervention?	Yes	No
If YES, please provide name, relationship to prospective patient, phone number, and e-mail address of person completing this intake:

Patient's Legal Name (First, Middle, Last):

Nick Name:

Home Phone:

Cell Phone:

Work Phone:

Home Address:		City:		County and State:
Zip:		Email:		Present Marital Status:

Date of Birth:

Age:

Sex:

SS#:

How many people live in your home including you?:

Dependent Children/Step (Names/Ages):

Emergency Contact Name/Next of Kin:		Relationship:
Address:		City:
County and State:		Zip:

Home Phone:

Cell Phone:

Work Phone:

REFERRAL SOURCE How did you first hear about Seabrook House? Other:

Name of therapist/counselor/family that referred you:
Address:		City:
County and State:		Zip:
Phone:		Cell Phone:

SOCIAL HISTORY

Current/past legal problems (DWI?- when?):

Lawyer name and phone number:

Current health (high BP, ulcers, diabetes, allergies, etc.):

Primary doctor name and phone number:

Current medications (name/dosage, amount/why prescribed):

Present/past alcohol/drug/pyschiatric treatment or hospitalization in past 5 years:	Dates:	How many days?	Did you complete?
			NoYes
			NoYes
			NoYes

ALCOHOL/DRUG USE	Date last used	How much on that date?	Average Frequency/ Average Amount
Primary substance
Secondary substance
Third substance

HEALTH INSURANCE INFORMATION (Patient is the Scubscriber)

Employer Name:		Employer Phone/Contact:
Address:		City:
County and State:		Zip:
Occupation:		How many years/months at present employer?:

PATIENT HEALTH INSURANCE

Insurance Name:	ID #:	Group #:
Please list ALL Telephone/800 #'s on your insurance ID card:

IF APPLICABLE, SECONDARY INSURANCE - Select subscriber relationship to patient

Name of subscriber:	DOB:	SS#:
Employer (name, address, and phone):

OTHER HEALTH INSURANCE

Insurance Name:	ID #:	Group #:
Please list ALL Telephone/800 #'s on your insurance ID card:

Any comments/questions from person completing this form:

Email address of person completing this form: