Pre-Admission Assessment - Season Luxury Rehabilitation Centre

Pre-Admission Assessment – Seasons Luxury Rehabilitation Center

Pre-Admission Assessment – Seasons Luxury Rehabilitation Center. Kindly fill out the following questions prior to admission.

Full Name

First

Last

Date of birth?

Allergies

Sex

Drug Of Choice?

Date And Time Of Last Use

What Substances?

What Route?

How Much?

Do You Drink Alcohol?

Date And Time Of Last Drink?

What Did You Drink? How Much?

An Children? You

How Many Days A Week Do You Drink?

Do You Use Iv Drugs?

Have You Ever Experienced Blackouts?

Do You Have A History Of Seizures?

If So, When Was The Last One?

Is It Only When You're Withdrawing?

Have You Ever Been On Buprenorphine Or Subutex?

Are You On Maintenance?

If So What's The Dose?

Have You Ever Had The Implant? If So When

Have You Been In Treatment Before?

When And Where? Did You Complete?

Do You Have Any Psychiatric Issue?

Co-occurring Disorders?

If So What Are They? (Example Depression Ptsd Anxiety)

Do You Have Any Medical History?

Did You Bring Any Medication With You?

Are You Prescribed Any Medication?

History Of Suicide Or Self-harm? When?

Substance Use History: What Substance?

How Old Are You When You First Started?

How Old Were You When You Took Your First Drug Or Drink?

List Them All Here To The Best Of Your Ability:

Do You Have A History Of Trauma, Abuse, Neglect, or Trafficking? Briefly Explain:

What Type Of Insurance Do You Have?

What's The Policy Number?

Do You Have Any Secondary Insurance?

If So What's The Name And Policy Number?

Do You Have Any Secondary Insurance If So With Who And What's The Subscriber Number

What's Your Longest Period Of Sobriety? When Was That And For How Long?

Do You Have Prescription Coverage?

If So, what is your PCN and Rx Bin Number?

Do You Have A Driver's License Or Identification Card?

If So From What State?

What's The Number? When Does It Expire?

What's Your Social Security Number

Marital Status? Do You Have Any Children?

Do You Have Any Legal Issues Due To Your Addiction Are You On Probation Parole Or Court Order?

What's Your Telephone Number? Do You Have An Emergency Contact? What's Their Name And Number?

Are You Currently Homeless? If So For How Long?

Are You Employed?

Do You Have A Regular Doctor? If So, What's Their Name And Number?

Comment or Message

Thank You For Completing This Form. Your Information Will Help Us Prepare The Best Possible Care For You At Seasons Luxury Rehabilitation Centre.