Intake Form - Rising Roads Recovery

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*

Potential Client's Full Legal Name*

Potential Client Email*

Date of Birth*

Parent's Current Address*

Who is the potential client living with right now?*

Is the potential client in treatment at this moment?*

If yes, 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 items 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?*

If so, when was the last attempt at suicide or self harm?*

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

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

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

Are you wanting to use insurance to offset the cost of treatment?*

Do you have any questions for Rising Roads Recovery?*

Security question, please answer the math question: What is 5+4?*

Fields marked with an * are required

Client Information Form

Contact Information

Resources

Forms