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General Information
How did you hear about us?
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Name of Person Filling out this form
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Relationship to Patient
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Phone Number
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Alternate Phone Number
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Email
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What State Are You Located In?
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Patient Information
Patient Legal Name
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D.O.B.
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Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Gender
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Form of Payment
Emergency Contact Name
Emergency Contact Phone Number
Do you give us permission to contact this person in an emergency?
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Admission Assessment
Are you a danger to yourself or others?
Yes
No
Have you had any past suicide attempts?
Yes
No
In the last 12 months, were there thoughts of suicide, with an intention/plan?
Yes
No
Currently, are there any thoughts of suicide along with an intention and plan?
Yes
No
Have you ever been hospitalized for a mental health condition?
Yes
No
List any medication(s) or food you are allergic to below (Leave blank if none)
Have you ever had a seizure?
Yes
No
List all current medications, dosage, and the reason they are prescribed?
Are you currently taking antipsychotic or other psychiatric medication?
Yes
No
Are you taking the medications as prescribed?
Yes
No
Do you have any diagnosed medical conditions?
Yes
No
Please list any immediate medical concerns
In the past 6 months, any rashes, wounds, lung diseases, or other infections?
Yes
No
Have you attended any drug and alcohol treatment centers in the past?
Yes
No
Do you drink alcohol?
Yes
No
Have you abused prescription medications or used street drugs in the past 12 months?
Yes
No
Date you last used drugs or drank alcohol?
Yes
No
In the past 12 months, have you been arrested?
Yes
No
Briefly describe your relationship with your immediate family:
In the past 12 months, have you held steady employment?
Yes
No
Please choose which option best describes your network of friends:
Please describe your willingness to be helped
Anticipated date of admission to The River Source
Anticipated length of stay at The River Source:
Did you find the program through one of our treatment Paths?
Yes
No
Do you have interest in participating in one of our paths?
Yes
No
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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I have read and fully understand all of the above.
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