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Name of Client: (First, Middle, Last)*

Contact (if you are completing this form for someone else, please enter your name):

Email:*

Phone:*

Sex:*
Male Female

Describe Any Special Needs You May Have:*
Detox Needed? Yes ____ No_____    Would an Intervention be helpful?     Extended-Care,  Sober-living DETAILS

Is the individual in treatment, or had treatment in the past. No Yes If yes, please tell us a little about the experiene below:
Please give us an idea of when the patient may want to come into treatment? 

Please explain; current physical & emotional conditions: Stress/Panic Attacks, Obsessive Compulsive Behavior; Anger-Pain *

Is the individual taking any prescription medication: No Yes
If yes please specify dosage and frequency:

Why do you think there is a problem?: When and why do you think the problem began?   Patient's occupation is-

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