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Admission Assessment
Are you a danger to yourself or others?
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Have you had any past suicide attempts?
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In the last 12 months, were there thoughts of suicide, with an intention/plan?
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Currently, are there any thoughts of suicide along with an intention and plan?
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Have you ever been hospitalized for a mental health condition?
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List any medication(s) or food you are allergic to below (Leave blank if none)
Have you ever had a seizure?
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Are you currently taking antipsychotic or other psychiatric medication?
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Do you have any diagnosed medical conditions?
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In the past 6 months, any rashes, wounds, lung diseases, or other infections?
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Have you attended any drug and alcohol treatment centers in the past?
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Do you drink alcohol?
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Have you abused prescription medications or used street drugs in the past 12 months?
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Date you last used drugs or drank alcohol?
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In the past 12 months, have you been arrested?
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In the past 12 months, have you held steady employment?
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Please describe your willingness to be helped
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Did you find the program through one of our treatment Paths?
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Do you have interest in participating in one of our paths?
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Application for Admission The River Source reserves the right to disqualify applicants for specific medical reasons that require a higher level of care. These medical reasons include, but are not limited to: Active Tuberculosis Suicidal Ideation with a Plan, Means, and/or Intent Acute Psychosis Infectious Disease A person who moves to a higher level of care will again become eligible for one of the programs offered at The River Source once their medical situation is successfully handled.
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