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Rehab Programs: Admin Application

Youth Admission Form

How Did You Hear About Us?:*
If Other, please explain:*
Please let us know how you found theriversource.org (friend or keywords)
Name of Person Filling Out This Form:*
Relationship to Patient:*
Email Address:*
Phone Number:*
Alternate Phone Number:
What state are you located in?:*
Patient Information
Male Patient's Legal Name:*
Male Patient's Phone Number:*
Age:*
Date of Birth:*
Date Format: MM slash DD slash YYYY
Responsible Party Information
Parent/Guardian Name:*
Relationship:*
Custody of Patient?:*
- Yes
- No
Home Number:*
Address:*
Street Address City State ZIP Code
Employer:*
Work Number:*
Other Parent or Guardian
Parent/Guardian Name:
Relationship:
Custody of Patient?:
- Yes
- No
Home Number:
Address:
Street Address City State ZIP Code
Employer:
Work Number:
Form of Payment:*
Address
Street Address City State ZIP Code
Is the patient a danger to their self or others?:*
- Yes
- No
If yes, please explain:*
Has the patient had any past suicide attempts?:*
- Yes
- No
If yes, when was his most recent attempt? What method was used?:*
In the last 12 months, has the patient had any thoughts of suicide, along with an intention and plan?:*
- Yes
- No
If yes, when was his last suicidal thought, along with an intention and plan?:*
Currently, does the patient have any thoughts of suicide along with an intention and plan?:*
- Yes
- No
If yes, please explain:*
Has the patient ever been hospitalized for a mental health condition?:*
- Yes
- No
If yes, please explain:*
Please list all medication and food allergies:*
Has the patient ever had a seizure?:*
- Yes
- No
If yes, when and what caused it?:*
Please list all current medications, dosage, and the reason they are prescribed:*
Is the patient currently taking antipsychotic or other psychiatric medication?:*
- Yes
- No
Does the patient currently have a 30 day supply of his antipsychotic or other psychiatric medication or does he have valid refills?:*
- Yes
- No
- If the patient does not have a 30 day supply of his antipsychotic or other psychiatric medication he may be required to see a psychiatrist or his physician who can prescribe the patient his medication. The patient's cost for this service is $100-$300 depending on his psychiatric service need.
Is the patient taking the medications as prescribed?:*
- Yes
- No
Please list any immediate medical concerns:*
In the past six months, has the patient had any rashes, wounds, abscesses, respiratory diseases, or other infections?:*
- Yes
- No
If yes, please describe the situation and the treatment that the patient received:*
Has the patient attended any drug and alcohol treatment centers in the past?:*
- Yes
- No
If yes, when was the date of his previous treatment?:
Date Format: MM slash DD slash YYYY
Does the patient drink alcohol?:*
- Yes
- No
Please specify how often the patient drinks alcohol:*
- Daily
- Weekly
- Monthly
- Yearly
- Binge Drink
How much does the patient drink?:*
- 1-2
- 3-4
- 5 or more
What type of alcohol?:*
- Beer
- Wine
- Liquor
Has the patient abused prescription medications or used street drugs in the past 12 months?:*
- Yes
- No
If yes, please list all substances used as well as how frequently the patient uses them:*
Date the patient last used drugs or drank alcohol?:*
Date Format: MM slash DD slash YYYY
In the past 12 months, has the patient been arrested?:*
- Yes
- No
If yes, why?:*
Briefly describe the patient’s relationship with their immediate family:*
Is the patient currently enrolled in school?:*
- Yes
- No
If not, why?:*
Please specify the patient's last grade completed in school:*
Does the patient have a:*
Please describe the patient’s willingness to be helped:*
Anticipated date of admission to The River Source:*
Date Format: MM slash DD slash YYYY
Anticipated length of stay:*
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 River Source program once medical situation is successfully handled.
*
- I have read and understood the above.

OUR PROGRAMS

Welcome to The River Source, the place where new beginnings are created. We commend you for taking the first step in your recovery, and we want you to know that we are here for you.

Help is Waiting, Call Now:

866-294-9331

We offer affordable private pay rates & accept most PPO and HMO insurances

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RESIDENTIAL TREATMENT CENTER

16286 S. Sunland Gin Rd
Arizona City, AZ 85123

OUTPATIENT TREATMENT CENTER

2325 W Guadalupe Rd STE 107,
Gilbert, AZ 85233

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