Rehab Center Patient Intake Form

Form Template

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.

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Language: English
Country: United States of America

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

  • Signature Capture
  • Conditional Fields
  • Submission Editing
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