RECOVERY HEALTHCARE CORPORATION TREATMENT: PERSONAL DATA FORM

Transcription

1 RECOVERY HEALTHCARE CORPORATION TREATMENT: PERSONAL DATA FORM For Office Use Only NEW CLIENT CLIENT RENEWAL CLIENT UPDATE CLIENT NETSUITE I.D.# Court Order - N/P Payment Identification - N/P Picture BrAC Level Scanned Contract For Office Use Only Phase I Phase II Phase III Aftercare DWI I DWI Basic Course WEST BIPP DOEP Anti-Theft Anger Management I Anger Management II MJ Intervention Parenting Class Other: Drug Patch UA GPS SCRAM CAM SCRAM RB Soberlink Interlock RF Other: DATE: (Contract must be accurate and complete. Enter N/A in any field that does not apply) LAST NAME: FIRST NAME: MIDDLE NAME: ADDRESS: _ APT # CITY: STATE: ZIP: HOME PHONE: CELL PHONE: SOCIAL SECURITY: - - DL/ID NUMBER: STATE: DATE OF BIRTH: AGE: SEX (Circle): M / F HEIGHT: WEIGHT: ETHNICITY: PRESCRIBED MEDICATIONS (Usage/Dosage): EMPLOYER NAME AND ADDRESS & PHONE: OCCUPATION: WAGE (salary/hourly): WORK SCHEDULE, DAYS & HOURS: MILITARY SERVICE (Circle): Y / N BRANCH: EMERGENCY CONTACTS: 1) RELATIONSHIP: PHONE: 2) RELATIONSHIP: PHONE: 3) RELATIONSHIP: PHONE: JUDGE: CAUSE #/CID # COUNTY: COURT #: NEXT COURT DATE: WHAT IS YOUR SUPERVISION LEVEL? (Circle) PROBATION/ PAROLE/ PRETRIAL/ BOND/ PHASE SUPERVISING OFFICER: PHONE: NEXT APPT. DATE: SUPERVISING OFFICER ADDRESS: ARE YOU CURRENTLY CHARGED WITH AN OFFENSE? (Circle) Y / N IF YES, WHAT IS CHARGE? ATTORNEY: PHONE: PARTICIPANT SIGNATURE: DATE: By signing this document I acknowledge that all of the information that I provided is accurate and true. Revised 06/04/2014

2 PRESENT MARITAL STATUS: never married married separated divorced widowed other, specify If married, how long? Married how many times? Number of Children: Their ages:,,,, How many years of schooling have you completed? Certificate received/graduated with (circle): None GED HS diploma Bachelors Masters Doctorate What type of work have you been trained to do? List the types of jobs you have held and reasons for leaving. Current Employment: Full Time Part Time Not Employed Disabled If unemployed, how long? Type of work you are seeking? Military History: Discharge Date: Type of Discharge: Rank at Discharge: Combat History: Yes No If yes, please explain: Have you ever attended any of the following courses in Texas: (Please check all that apply) DWI Basic Education DWI Intervention (Repeat Offender) Drug Offender Education Drug Intervention Theft 2

3 INFORMATION CONCERNING THE ARREST THAT BROUGHT YOU HERE: Date of arrest: Time of arrest: County of arrest: Reason for arrest: Speed you were traveling: Lawful Speed: Was an accident involved? Yes No Was anyone injured? Yes No If yes, how many? Was anyone killed? Yes No If yes, how many? Did you take the Breath or Blood test? Yes No If yes, what were the results? Previous arrest breath/blood test results: ; ; ; What was the status of your driver s license at the time of the arrest that brought you here? OK Revoked Suspended Business Purposes Only Has your license ever been under any of these conditions? ( including now) suspended ( number of times) revoked ( number of times) business purposes only ( number of times) If suspended or revoked, what were the reasons? PREVIOUS ARREST INFORMATION How many times have you been arrested for any reason? Please list all charges (DWI, Possession Charge, DWLS, PI, ASSAULT, ROBBERY, BURGULARY, PROBATION REVOCATION, THEFT, PROSTITUTION, AND ANY OTHERS THAT MAY APPLY), dates and case disposition information. CHARGE DATE CASE DISPOSITION Number of arrests which involved alcohol/drugs: Age at your first arrest: Age at your first drug/alcohol-involved arrest: AT WHAT AGE DID YOU BEGAN DRINKING? Have you ever thought you might have a drinking problem? Yes No Have you ever thought you might have a drug problem? Yes No 3

4 Do you feel your drinking or drugging has contributed to any family problems now or in the past? Yes No. If Yes, please explain: Have you ever received help for either a drinking or drug problem? Yes No Not Applicable If yes, please check the appropriate source: Family Doctor Alcoholics Anonymous Church Alcohol rehabilitation program Name/Address Drug rehabilitation program Name/Address Psychiatrist Relative Agency (please give name) Other (please explain) EMERGENCY CONTACT: Name/Relationship to you: Address Telephone: (W) (H) Signature Date 4

5 SUBSTANCE ABUSE HISTORY Check/circle all mood altering substances you are currently using or have used. ALCOHOL OPIATES Heroin, Methadone, Darvon, Morphine Codeine, Talwin, Dilaudid CANNABIS/ HASHISH STIMULANTS Marijuana / Hashish Amphetamines, Ritalin, Tenuate, Rital Preludin MINOR TRANQUILIZERS PHENCYCLIDINE Valium, Librium, Serax, Tranxene PCP Miltown, Equanil, Xanax COCAINE HALLUCINOGENS LSD, DMT, Mescaline SEDATIVES / BARBITUATES INHALANTS Secobarbital, Amytal, Placidyl, Doriden Noludar, Phenobarbital, Dalmane, Restoril Quaalude, Sopor OTHER (please list) Substances primarily used (List in order of priority/preference of use: Normal Pattern of use/drinking (include frequency, amount, type of substances/alcohol): Where do you usually use alcohol/drugs? (Circle any that apply) Party or social event Work Home by self-home with family with friends On the street Night Club Other: 5

6 Check any of the symptoms/consequences of drinking/drug use you have experienced: Tolerance change Convulsions Physical/Health Problems Daily use for 2+ Nausea/Vomiting Emotional/Psychiatric Problems Loss of control Sweating Personal Problems Withdrawal symptoms Muscle Cramps Job/School problems Tremors/Shakes Morning use Diabetes Legal problems Blackouts/Memory loss Hallucinations DT s passing out/fainting High blood pressure Have you ever become involved in a self-help group followed by 3 months of continuous sobriety? Name of group (AA, NA, church, etc): If AA/NA, which group Date first attended (month/year): Frequency of attendance (how many times per week): Did/Do you have a sponsor? Yes No Have you ever completed formal treatment? Yes No Not Sure If yes: Inpatient Outpatient Other Number of times Dates: ; ; ; Name/Address of Facility Please describe any other periods of time you did not drink or use drugs other than noted above: 6

7 FAMILY HISTORY OF ALCOHOLISM/SUBSTANCE ABUSE AND PSYCHIATRIC PROBLEMS PLEASE CIRCLE APPLICABLE RESPONSE: ALCOHOLISM/DRUGS PSYCHIATRIC PROBLEMS 1. Grandparents Y N Unk Y N Unk. If you circled Y, please circle which grandparent: Maternal Grandmother/Grandfather Y N Unk. Paternal Grandmother/Grandfather Y N Unk 2. Mother Y N Unk Y N Unk 3. Father Y N Unk Y N Unk 4. Brother/Sister Y N Unk Y N Unk 5. Children Y N Unk Y N Unk 6. Current Spouse Y N Unk Y N Unk 7. Other Family: Y N Unk Y N Unk If yes, please list relation to you, including stepparents or in-laws: If you answered yes above, please describe the type of substance dependence or psychiatric condition: 7