Medium

Available on

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Rehab Center Patient Intake Form Mobile App

The Rehab Center Patient Intake Form is a great form for rehab centers and drug treatment programs to use in treating patients with substance abuse problems. Rehab programs must collect a great deal of information about a patient's drug abuse and alcohol addiction during the intake process for rehab. This form highlights important categories such as psychological, employment, educational/vocational, legal status, current drug use, and drug treatment history. These categories provide a deeper insight into the substance abuse history of the patient, and can help to tailor the goals of the treatment program to deliver the best possible substance abuse treatment from the point of the rehab patient intake onwards. The form allows detailed input of the primary and secondary drug use of each patient, including date of last use, amount used, method of admission etc, for many drugs such as heroin, alcohol, cocaine, marijuana etc

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Rehab Center Patient Intake Form Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico date

    Date of Admission:

  • Ico checkbox

    Methadone Maintenance

  • Ico checkbox

    Detoxification

  • Ico textbox

    Name (Last, First, Middle Initial)

  • Ico textbox

    Address/Apartment Number:

  • Ico textbox

    City:

  • Ico dropdown

    State:

  • Ico integer

    Zip Code:

  • Ico textbox

    Phone Number:

  • Ico date

    Date of Birth:

  • Ico textbox

    Social Security Number:

  • Ico dropdown

    Sex:

  • Ico textbox

    Race:

  • Ico dropdown

    Do you currently have a MediCal?

  • Ico dropdown

    Do you have a Drivers License?

  • Ico dropdown

    Are you a veteran?

  • Ico textbox

    Type of Discharge:

  • Ico dropdown

    How will you get the clinic?

  • Ico dropdown

    Marital Status:

  • Ico textbox

    Other Marital Status:

  • Ico dropdown

    Religious Preference:

  • Ico textbox

    Other Religious Preference::

  • Ico dropdown

    Sexual Orientation:

  • Ico dropdown

    Social Preference/Living Apartments

  • Ico textbox

    Current Number of People in Your Home:

  • Ico textbox

    Other Social Preference/Living Arrangement:

  • Ico dropdown

    Employment Status

  • Ico textbox

    Length of Employment:

  • ...and More!

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