Intake Form - Rising Roads Recovery

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Client Information Form

Fields marked with an * are required

Initial Intake Form

"*" indicates required fields

Your Name*

Your Relationship to Potential Client*

Your Phone Number*

Your Email*

Potential Client's Full Legal Name*

Date of Birth*

MM slash DD slash YYYY

Current Mailing Address*

Who is the potential client living with right now?*

Is the potential client currently in treatment?*

Yes

No

If yes, where and for how long?*

Is the potential client adopted?*

Yes

No

If yes, at what age and from where?*

How did you hear about Rising Roads Recovery?*

To the best of your knowledge: What medications is the potential client on?*

To the best of your knowledge: Do you know what the potential client drinks and/or what kind of drugs they are using or have used?*

To the best of your knowledge: How long has the potential client been abusing the substances above?*

Do you know if the potential client has had any suicide attempts or suicidal thoughts? Has the potential client engaged in any self-harm behaviors in the past or are they currently self harming?*

Yes

No

If so, when was the last attempt at suicide or self harm? Please be as detailed as possible.*

To the best of your knowledge: Are there any medical issues Rising Roads should be aware of?*

Yes

No

If so, please list all medical issues you are aware of*

Is there anything you believe Rising Roads Recovery should know?*

If possible, are you wanting to use insurance to offset the cost of treatment?*

Yes

No

If yes, please fill out the insurance verification form here.
Please make sure to complete and submit this form as well.

Do you have any questions for Rising Roads Recovery?*

Δ

Fields marked with an * are required

DHCS - California Department of Health Care Services

Contact Information

3151 Airway Ave, Suite I3
Costa Mesa, Ca 92626

1-866-746-1558

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