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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:*
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?:
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?:*
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:*
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.

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

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The River Source - Arizona IOP Drug & Alcohol Rehab

108 E 2nd Ave
Mesa, AZ 85210

The River Source - Arizona Drug Rehab Program

16286 S Sunland Gin Rd
Arizona City, AZ 85123

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