Addiction Treatment Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Age
Gender
Female
Male
Other
Prefer not to say
Phone Number
Address
Emergency Contact
Name
Phone Number
Relationship
Insurance Information
Insurance Provider
Policy/Member ID
Group Number
Substance Use History
Which substances are you seeking treatment for?
How long have you used these substances?
Date of last use
Have you participated in addiction treatment before? If yes, please describe.
Medical History
Current/past medical conditions
Current medications
Allergies
Mental Health
Current/past mental health diagnoses or concerns
Current psychiatric medications
Other Information
Any legal issues?
What are your goals for treatment?