Client Application Form | Red Oak Recovery

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

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

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):*

Insurance Information
Primary Insurance Company
Address
Benefits Phone
Group number
Policy number
Policyholder's name
Employer
DOB
Date Format: MM slash DD slash YYYY
SSN
Secondary insurance company
Address
Benefits phone
Group number
Policy number
Policyholder's name
Employer
DOB
Date Format: MM slash DD slash YYYY
SSN
Parents Marital Status (Combined)
Placement/Intervention 1 (Combined)
Placement/Intervention 2 (Combined)
Placement/Intervention 3 (Combined)
Primary Relationship (Combined)
Secondary Relationship (Combined)

Step 1 of 8

Client Information

Parent/Guardian/Sponsor Information

Placement Information

Placement/ Intervention History

Psychological History

Medical Information

Insurance Information

INSURANCE & FINANCES