Is this form being completed as part of a family/employer intervention? Yes No
If YES, please provide name, relationship to prospective patient, phone number, and e-mail address of person completing this intake:

Patient's Legal Name: Nick Name:

Home Phone: Cell Phone: Work Phone:

Home Address: City: County and State:
Zip: Email: Present Marital Status:

Date of Birth: Age: Sex: SS#:

How many people live in your home including you?: 

Dependent Children/Step (Names/Ages):


Emergency Contact Name/Next of Kin: Relationship:
Address: City:
County and State: Zip:
Home Phone: Cell Phone: Work Phone:
REFERRAL SOURCE

How did you first hear about Seabrook House?    Other: 
 
Name of therapist/counselor/family that referred you:  
Address: City:
County and State: Zip:
Phone: Cell Phone:

SOCIAL HISTORY
 
Current/past legal problems (DWI?- when?):
Lawyer name and phone number:
Current health (high BP, ulcers, diabetes, allergies, etc.):
Primary doctor name and phone number:
Current medications (name/dosage, amount/why prescribed):
Present/past alcohol/drug/pyschiatric
treatment or hospitalization in past 5 years:		 Dates: How many days? Did you complete?
NoYes
NoYes
NoYes

ALCOHOL/DRUG USE Date last used How much on that date? Average Frequency/
Average Amount
Primary substance 
Secondary substance 
Third substance 

HEALTH INSURANCE INFORMATION  (Patient is the Scubscriber)
 
Employer Name: Employer Phone/Contact:
Address: City:
County and State: Zip:
Occupation: How many years/months
at present employer?:

PATIENT HEALTH INSURANCE
 
Insurance Name: ID #: Group #:
Please list ALL Telephone/800 #'s on your insurance ID card:

IF APPLICABLE, SECONDARY INSURANCE - Select subscriber relationship to patient 
 
Name of subscriber: DOB: SS#:
Employer (name, address, and phone):

OTHER HEALTH INSURANCE
 
Insurance Name: ID #: Group #:
Please list ALL Telephone/800 #'s on your insurance ID card:

Any comments/questions from person completing this form:


Email address of person completing this form: