Veterans Substance Use Recovery Admission Sheet
Personal Information
Full Name
Date of Birth
SSN
Contact Number
Address
Military Background
Branch
Dates of Service
Rank at Discharge
Type of Discharge
Emergency Contact
Name
Relationship
Phone Number
Address
Substance Use History
Substances Used
Duration of Use
Date of Last Use
Previous Treatment Programs
Medical History
Medical Conditions
Allergies
Current Medications
Primary Care Provider
Mental Health History
Mental Health Diagnoses
Counseling/Psychiatric History
Current Symptoms
Goals for Recovery
Admission Date
Staff Use Only
Staff Signature