Cri-Help Drug and Alcohol Treatment in Southern California

F Cri-Help Drug and Alcohol Treatment in Southern California

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We know that making the decision to get help for addiction is difficult.
Cri-Help's staff is devoted to making sure you get the right help, right away.
Please contact our Admissions Department at 800.413.7660 with any questions to start the process of RECOVERY NOW!

If you wish, you may get started by completing the Pre-Admission Assessment form below.
This takes about 10-15 minutes, and will equip us to respond to your individual needs.

Pre-Admission Assessment Form

Date:

How did you find us: if other, specify:

Last name:

First name:

Alias:

Email:

Telephone:

Gender:

Birth date:

LAST CURRENT RESIDENCE *AND LIVING WITH WHOM:

Address:

City, State, Zip:,

Telephone:

*Name:, Relationship:

Are you currently receiving: SSI Status:, GR Status:, AFDC Status:

INSURANCE:

Do you have Medical Insurance: If yes, Name of Insurance Company:

Subscriber#:

Telephone:

WORK HISTORY:

Are you currently employed:

If yes, Name of Company:

Address:

City, State, Zip:,

How long at present job:

Current Status:

Will you be returning to work after treatment:

FAMILY:

Marital Status:

Do you have any children:, if yes, how many: , ages:

Who is the primary caretaker of the children:

Receiving AFDC:

Do you have family support:, if yes: , if so, whom:

Is anyone in your family or support system involved in a 12-Step Program:

Is anyone in your family or support system presently using drugs:

Is anyone in your family or support system currently residing at or employed by Cri-Help, Inc.:

EMERGENCY CONTACT:

In case of an emergency, who would you like us to contact:

Name:

Relationship:

Telephone:

DRUG HISTORY: Current drug problem(s):

Primary Drug:, frequency:, Route:

Secondary Drug:, frequency:, Route:

Tertiary Drug:, frequency:, Route:

Comments:

I.V. Drug User:

When was the last time you used:Date: , Time:

What drugs:

How have you supported your drug use:

DISCHARGE PLANS:

What are you planning to do after you have completed detox/residential treatment:

Entering Residential Program:, if yes, what program:

Entering Outpatient Program:, if yes, what program:

Going to Sober Living house: , if yes, what sober living:

Attending 12-Step Meetings only:

LEGAL INFORMATION:

Court appearances pending: , Charge: , Where: , Date:

Traffic violations pending:, Charge: , Where: , Date:

Outstanding warrants pending:, Charge: , Where: , Date:

Have you ever been convicted of a felony:

On probation:, Violations:, for what reason:

Probation X#:

P.O.'s Name:

Telephone:

Office Address or Area:

On parole:, Violations:, for what reason:

CDC#:

Parolee Agent Name:

Telephone:

Office Address or Area:

Private Attorney:, Telephone:

Public Defender:, Telephone:

Currently doing time:, Where:, Booking Number:

Release Date:, Where are you to report upon release from jail/prison:

Court order for release to Cri-Help:

Are you currently in a Substance Abuse Program:, if yes, which program are you enrolled in and where:

MEDICAL EVALUATION:

Do you have any physical limitations:, if yes, explain:

Medical Problems:, if yes, explain:

Seizures:, if yes, last time you had a seizure:

Are you allergic to any medications:, if yes, list medications:

Do you think you many be pregnant:, comments:

Last time you had a tuberculosis test:

When was the last time you saw a doctor:, Reason:

Are you currently under a doctors care:, if yes, reason:

Dr. Name:, Telephone:

Are you currently taking any medications:, if yes, is prescribing doctor aware of illegal drugs used:

What medication and dosage:, for what purpose:

How long have you been on it:, Last time you took it:

PSYCHIATRIC HISTORY:

Do you feel you have ever had any significant emotional problems in your life:, if yes, please describe:

Have you ever been or are you currently under the care of a counselor or therapist:, if yes, Therapist name:, length in therapy:

Does you therapist or prescribing doctor know you have been taking illegal drugs:

Are you now, or have you ever been, on antidepressants or any other psychotropic medications:

What medications and dosage:, for what purpose:

How long have you been on it:, Last time you took it:

Have you ever felt like injuring or killing yourself:, if yes, please explain:

Have you ever tried:, if yes, please describe how and how many attempts:

Do you feel that way now:, if yes, please explain:

Have you ever felt like injuring or killing someone else:, if yes, please explain:

Have you ever tried:, if yes, please describe:

Have you ever heard voices that others couldn't hear, seen things that others couldn't see, smelled things that others couldn't smell:, if yes, please explain:

Is there anything we haven't already asked you about, that you think we should know so that we may better assist you?:

if yes, please explain:

All the information that I have provided is true and correct and I have no further information to provide regarding these matters. I understand that it is my responsibility to update any and all information that I provided prior to my admission to Cri-Help, Inc. and that failure to do so can result in my being discharged from the facility.

Your information is strictly confidential. Submitting this form means that you agree to all terms and conditions.

Enter your Email address: