Client Application Form

You are here:

Home
Addiction Treatment Admissions
Client Application Form

Step 1 of 9

11%

Date Submitted*
Date Format: MM slash DD slash YYYY
Client Information
Name*
Gender*
- Male
- Female
DOB*
SSN
Expect to enroll
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Country
Mobile phone*
Email*
Ethnicity
Height
Weight
Eyes
Hair
Shoes
Shirt
Waist
School grade
Religious preference

Parent/Guardian/Sponsor Information
PRIMARY – Name
PRIMARY – Relationship
PRIMARY – Sponsor
- Yes
PRIMARY – Legal custody
- Yes
PRIMARY – Physical custody
- Yes
PRIMARY – Emergency contact
- Yes
PRIMARY – Parent guardian
- Yes
PRIMARY – DOB
Date Format: MM slash DD slash YYYY
PRIMARY – SSN
PRIMARY – Address
PRIMARY – City
PRIMARY – State
PRIMARY – Zip
PRIMARY – Mobile phone
PRIMARY – Email
PRIMARY – Home fax
PRIMARY – Job title
PRIMARY – Employer
PRIMARY – Work email
SECONDARY - Name
SECONDARY - Relationship
SECONDARY - Sponsor
- Yes
SECONDARY - Legal custody
- Yes
SECONDARY - Physical custody
- Yes
SECONDARY - Emergency contact
- Yes
SECONDARY - Parent guardian
- Yes
SECONDARY - DOB
SECONDARY - SSN
SECONDARY - Address
SECONDARY - City
SECONDARY - State
SECONDARY - Zip
SECONDARY - Mobile phone
SECONDARY - Home email
SECONDARY - Home Fax

How did you first hear about Red Oak Recovery^®?
If you used a search engine, what search terms were used?
Please give the name(s) of the referral source including phone, fax number and email:
Reason for referral

Family Information
Parents' current marital status
If applicable, date of divorce/separation
Date Format: MM slash DD slash YYYY
How do you believe the divorce/separation has affected the applicant? Please explain
Describe the visitation arrangement
Is the applicant adopted? - Y*
- No
- Yes
If adopted, at what age?
Important circumstances surrounding the adoption process or afterwards
Number of siblings
Name, age, current residence, and health of each sibling, if applicable
Where was the applicant born? Include city, state, country and physical location: hospital, home, etc.
Were there any complications during birth mother's pregnancy or delivery? If yes, please explain:

Placement Information
What specific events precipitated your decision to seek treatment?
What are your specific goals for the applicant while receiving treatment?
What would you describe as the applicant's strengths? (intellectually, artistically, socially, physically, etc)
What would you describe as the applicant's weaknesses? (intellectually, artistically, socially, physically, etc)
Describe the applicant's experience with the outdoors and other physical activities
Do you have any plans for future placement?

Placement/ Intervention History
Placement/intervention 1
Placement/intervention 1 - Contact?
- No
- Yes
Placement/intervention 1 - Location
Placement/intervention 1 - Dates
Placement/intervention 1 - Provider
Reason for placement/intervention and outcomes
Placement/intervention 2
Placement/intervention 2 - Can we contact?
- No
- Yes
Placement/intervention 2 - Location
Placement/intervention 2 - Dates
Placement/intervention 2 - Provider
Reason for placement/intervention and outcomes
Placement/intervention 3
Placement/intervention 3 - Can we contact?
- No
- Yes
Placement/intervention 3 - Location
Placement/intervention 3 - Dates
Placement/intervention 3 - Provider
Reason for placement/intervention and outcomes
Has the applicant had any psychological testing? If yes, please describe (include date/reason):
Note: Please fax/email/mail all previous testing from the last 3 years as part of this application.
Please describe anything of note regarding ethnicity, race, religion, nationality, and/or sexual orientation:

Psychological History
Please describe any major events the applicant has struggled with (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.), including the date the event occurred:
Describe the ways in which the applicant expresses anger
Has the applicant had any physical confrontations in the home or with others? If yes, please describe in detail including dates, persons involved, and circumstances that induced the event:
Has the applicant ever intentionally hurt him/herself? If yes, please describe in detail (include date, reason, what was used, where on the body the self-harm occurred, if medical attention was needed, how many times it occurred, and/or for how long):
Has the applicant ever run away? If yes, please describe (specify date, how long applicant ran away for and where, if the applicant had contacted you, etc.):
Has the applicant ever had thoughts of suicide, made a plan, or attempted suicide? If yes, please describe in detail (specify date, reason, if thoughts are active or passive, manipulation, and/or general history):
Please describe any risky, aggressive or inappropriate sexual behaviors of the client (promiscuity, unprotected sex, perpetrating, deviance, etc.):
Does the applicant exhibit signs of anxiety, depression, mood swings, etc.? If yes, please describe in detail with examples and dates when behaviors were exhibited:
Does the applicant experience recurrent thoughts or repeated behaviors that he/she cannot control? If yes, please describe in detail, and include dates:
Does the applicant have a history of lying, stealing, vandalism, dealing drugs, and/or criminal activity? If yes, please describe in detail, and include dates:
Please check all the unusual behaviors that apply to the applicant:
- Delusions
- Hallucinations
- Paranoid thinking
- Nightmares
- Tics
- Stuttering
- Bedwetting
- Head banging
Please describe in detail, including dates:
Does the applicant have a history of eating issues, current or past? If yes, describe in detail, and include dates:
Does the applicant have problems with isolation? If yes, please describe in detail:*
Does the applicant have any alcohol, substance abuse, and/or dependency-related issues?*
Substance usage
Does the applicant need detox prior to coming to Red Oak Recovery^®? If so, explain:*
Has there been a family history of drug or alcohol abuse? If so, please describe (include who/relationship, problem area, current status):*
Have there been other addictive patterns (e.g. video games, TV, internet, sex, gambling)? If so, please describe:*
Have there been any legal problems? If so, please list any charges, convictions, misdemeanors, felonies, probation and current legal status:*
Is there a family history of mental illness (e.g. depression, anxiety, etc.)? If so, please describe (include who/ relationship, problem area, current status):*

Medical Information
Family Doctor*
Phone
Family Dentist
Has the applicant ever had a seizure? If so, please provide dates and a detailed description of the event(s):*
Phone
Does the applicant wear glasses or contacts?
Date of last physical
Date Format: MM slash DD slash YYYY
Doctor
Reason
Has the applicant had any head injuries, loss of consciousness, or concussions? If so, please provide dates and a detailed description of the event(s):*
Is the applicant currently taking any prescribed or over-the-counter medications? If so, provide details below.
Are there any known side effects of the medication(s)? If so, please describe:*
Please describe previous history of medication(s), including the name of medication, dosage, reason, and prescribing physician:*
Is the applicant currently taking any vitamins or supplements? If so, please describe:*
Does the applicant currently get exercise? If so, please describe:*
Describe any pertinent medical/physical information that might inhibit physical activity:*
Does the applicant have any dietary restrictions? If so, please describe:*
Does the applicant have any dietary preferences? If so, please describe:*
Does the applicant currently have or ever had any of the following?
- Allergies
- Anaphylactic shock
- Anemia
- Ankle problems
- Anorexia/bulimia
- Appendicitis
- Arm problems
- Arthritis
- Asthma
- Back problems
- Bedwetting
- Bladder/kidney problems or infection
- Bleeding disorder
- Bone condition
- Bowel problems
- Broken bones
- Cancer
- Chest pains
- Chronic cough
- Circulation issues
- Colds (frequent)
- Constipation
- Cysts/tumors
- Dermatitis
- Diabetes I/II
- Diarrhea
- Difficulty walking or lifting
- Ear infections
- Endocrine problems
- Excessive sweating
- Fainting/dizziness
- Family history of heart disease
- Foot problems
- Frequent colds/sore throats
- Frequent heartburn
- Frequent muscle cramps
- Frequent shortness of breath
- Frostbite
- Gas/bloating
- HIV/AIDS
- Head traumas
- Headaches/migraines
- Hearing impairment
- Heart problems/murmurs
- Hepatitis A/B/C
- Hernia
- High blood pressure
- Hypoglycemia
- Intolerance to cold
- Intolerance to heat/overheats easily
- Irregular heartbeat
- Joint injuries
- Kidney problems
- Knee problems
- Leg problems
- Liver problems
- Lung infections
- Medical equipment or devices
- Meningitis
- Menstrual problems/ heavy bleeding
- Mononucleosis
- Motion sickness
- Obesity
- Other
- PMS - severe symptoms
- Pneumonia/bronchitis
- Pregnancy
- Recurrent injury/surgery
- STDs
- Scoliosis
- Seizures/epilepsy
- Shoulder problems
- Skin diseases/problems
- Sleepwalking
- TB - Positive test
- TB - Recent exposure
- TB - Tuberculosis
- Thyroid problems
- Ulcers
- Unexpected weight loss
*
- By checking this box, I am attesting that all of the above medical conditions have been reviewed and that the applicant has never experienced any of the boxes left unchecked.
Please describe any checked item in full detail, including dates, symptoms, and thorough explanation:*
Is the client up to date on immunizations?
- Yes
- No
Date of last immunization
Tetanus/Diptheria
Measles/Mumps/Rubella
Hepatitis B
Polio
Does the applicant have allergies or asthma? If so, provide details below:
Does the applicant carry an inhaler or epinephrine pen? If so, please list name/type of inhaler:*
Has the applicant ever been hospitalized for allergies/asthma? If so, please describe (include date/reason):*
Please list any pertinent medical history in the applicant’s family:*