Client Intake Form - Rockland Treatment Center

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Pre-Screening Admission Form

Please try your best to fill out the form below. If you have any questions, please call our client intake coordinators at 727-220-2422.

"*" indicates required fields

Client First Name*

Client Last Name*

Client Mobile Phone*

Client Email Address

Do you currently have a home address?*

Yes

No

Address

Street Address Address Line 2 City State ZIP Code

If no address is available, please write "NA" in the address field.

Do you have health insurance?*

Yes

No

Name of Insurance

Insurance Policy Number

Date of Birth (mm/dd/yyyy)*

Month

Day

Year

Do you have a Primary Care Provider (PCP)?*

Yes

No

Who is your Primary Care Provider (PCP)?

Date Last Seen by PCP

Month

Day

Year

Are you currently seeing a therapist?*

Yes

No

Current Therapist/Counselor

Date Last Seen by Therapist/Counselor

Month

Day

Year

Are you currently under any type of Guardianship?*

Yes

No

If yes, please provide name and contact info:

Do you have any children under the age of 18?*

Yes

No

Do they live in the home with you?

Yes

No

Are you the custodial parent?

Yes

No

Do you have an open DCF case plan?

Yes

No

Do you have an assigned case worker?

Yes

No

What are the problems you are seeking treatment for?*

What are your treatment goals? What would you like to work on if admitted?*

Please select the following symptoms when you're not using substances:*

Depressed Mood

Unable to enjoy activities

Sleep pattern disturbance

Loss of interest

Crying Spells

Hallucinations

Excessive guilt

Fatigue

Racing thoughts

Impulsivity/Risky Behavior

Excessive worry

Paranoia

Forgetfulness/lack of concentration

Change in appetite

Excessive energy

Increased Irritability

Anxiety Attacks

Isolation

None of these

Do you experience hallucinations?*

Yes

No

Are your hallucinations Auditory or Visual?

Auditory

Visual

What kind of things are you hearing or seeing? Are voices telling you to do things like harm yourself or someone else?

Do medications help your symptoms improve?

Yes

No

Risk Assessment:

Have you ever attempted suicide?*

Yes

No

If yes, please explain how and when:

Have you ever had feelings or thoughts that you didn’t want to live?*

Yes

No

Do you have those thoughts now?

Yes

No

How often?

Do you have a plan?

Yes

No

Are you currently taking any medications?*

Yes

No

If yes, please list ALL current medications: Medication Name, Total Daily Dosage and Estimated Start Date:

Medical History

Do you have current or past medical problems or past surgeries ex. Heart stint, open wound with packing, hypertension?*

Yes

No

If yes, please explain:

Have you ever had a seizure?*

Yes

No

When was your first seizure?

How old were you?

When was your last seizure?

Do you currently receive any treatments for seizures?

Yes

No

Have you ever sustained an injury due to a seizure?

Yes

No

Please describe:

Psychiatric History

Outpatient Treatment?*

Yes

No

Outpatient Treatment - please describe which facility/provider, when and nature of treatment?

Residential/Inpatient Treatment?*

Yes

No

Residential/Inpatient Treatment - please describe which facility/provider, when and nature of treatment?

History of Psychiatric Diagnosis?*

Yes

No

History of Psychiatric Diagnosis - please describe which facility/provider, when, and nature of treatment?

Psychiatric Hospitalization?*

Yes

No

Psychiatric Hospitalization - describe which facility, when, the reason and outcome?

Past Psychiatric Medications?*

Yes

No

Past Psychiatric Medications - name, dosage, last date and was it helpful?

Family Psychiatric History: Has anyone in your family been diagnosed with or treated for mental health?*

Yes

No

Family Psychiatric History: Who and what was diagnosis. Ex. Schizophrenia, Bipolar, Depression, Anxiety, Suicide etc.

Do you have a history of being abused emotionally, physically, sexually or by neglect?*

Yes

No

History of abuse during:

Childhood

Adulthood

Both

Do you have a history of self-harm?*

Yes

No

When was the last time you self-harmed?

What method of self-harm (cutting, burning, etc.)?

Do you currently have or have a history of an eating disorder?*

Yes

No

If yes, please describe:

Substance Abuse History

Do you have a history of substance abuse?*

Yes

No

Alcohol

Yes

No

Alcohol: how long, how much, and when was last use?

Cocaine

Yes

No

Cocaine: how long, how much, and when was last use?

Methamphetamine

Yes

No

Methamphetamine: how long, how much, and when was last use?

Opiates

Yes

No

Opiates: how long, how much, and when was last use?

Marijuana

Yes

No

Marijuana: how long, how much, and when was last use?

Heroin

Yes

No

Heroin: how long, how much, and when was last use?

Ecstasy

Yes

No

Ecstasy: how long, how much, and when was last use?

Methadone/Suboxone

Yes

No

Methadone/Suboxone: how long, how much, and when was last use?

Hallucinogens

Yes

No

Hallucinogens: how long, how much, and when was last use?

Benzo (i.e. Ativan, Xanax, Valium, Klonopin, Halcion)

Yes

No

Benzo: how long, how much, and when was last use?

Have you ever overdosed?*

Yes

No

Overdose: how long ago and what did you overdose from?

Other History

Tobacco - Currently smoking cigarettes?*

Yes

No

Currently Smoking Tobacco: how many packs per day on average?

Currently Smoking Tobacco: when was the last time consumed, and how much?

Tobacco - Past history of smoking cigarettes?*

Yes

No

Past History of Tobacco use: how many years did you smoke cigarettes?

Caffeinated Beverages?*

Yes

No

Caffeinated Beverages: how many do you drink a day?

Caffeinated Beverages: when was the last time consumed, and how much?

Have you or your family had any concerns over your gambling habits in the last 12 months (e.g. slot machines, sports betting, lottery games, online wagering, card games, stock market or cryptocurrency day trading, etc.) where you placed money or property at risk on an uncertain outcome?*

Yes

No

During the past 12 months, have you become restless, irritable or anxious when trying to stop/cut down on gambling?

Yes

No

During the past 12 months, have you tried to keep your family or friends from knowing how much you gambled?

Yes

No

During the past 12 months, did you have such financial trouble as a result of your gambling that you had to get hep with living expenses, from family, friend or welfare?

Yes

No

Legal History

Have you ever been arrested?*

Yes

No

If yes, please explain:

What were the charges?

What state and county were you arrested in?

Do you have any current legal problems or pending legal issues?*

Yes

No

If yes, please explain your current or pending legal problems:

Have you ever been arrested for Domestic Violence?*

Yes

No

If yes, please explain:

What state and county were you arrested in for Domestic Violence?

How long ago were you arrested for Domestic Violence?

Do you have or ever had aggressive behaviors ie. physical fights, breaking things?*

Yes

No

Please explain your aggressive behaviors:

COVID19 Protocols

Do you have any of the following symptoms that are not caused by another condition?*

Fever or chills

Cough

Shortness of breath or difficulty breathing

Fatigue

Muscle or body aches

Headache

Recent Loss of taste or smell

Sore throat

Congestion

Nausea or vomiting

Diarrhea

None

Within the past 14 days, have you been in close contact with anyone that you know had COVID-19 or COVID-like symptoms (close contact is being within 6 feet for 15 minutes or more over a 24-hour period with a person; or having direct contact with fluids from a person with COVID-19 with or without wearing a mask?*

Yes

No

Have you had a positive COVID-19 test for active virus in the past 10 days, or are you awaiting results of a COVID-19 test?*

Yes

No

Within the past 14 days, has a public health or medical professional advised you to self-monitor, self-isolate or self- quarantine because of concerns about COVID-19 infection?*

Yes

No

Have you been tested for COVID-19 within the last 7-10 days?*

Yes

No

What were the COVID-19 test results?

Positive

Negative

Notes

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