Shadow Mountain Recovery Application

Location of Interest

Client Information
Name:
Gender:
Height:
Weight:
Date of Birth:
Age:
Address:
City: State: Zip:
Phone Number:
Email:

Emergency Contact:
Name: Relationship:
Phone Number:
Email:
Address:
City: State: Zip:
Permission to contact?  Yes No

Person Financially Responsible
Person Financially Responsible (if not self):
Name: Relationship:
Phone Number: Mobile Number:
Home email address: Home Fax:
Address:
City: State: Zip:
Briefly describe your relationship with this person:

Insurance Information:
Insurance Company:
Policy/Member Number: Group Number:
Insurance Phone Number: Insurance Type:
Rx Number: Rx Group Number:
Rx Phone Number:
Rx BIN: Rx PCN:
Policyholder's Name:
Policyholder's Relationship to Applicant:
Policyholder's Date of Birth:
Policyholder's Social Security Number:
Policyholder's Employer:

Referral Information:
How did you first hear about Shadow Mountain Recovery?
Name: Phone Number:
Email address:

Placement Information
What specific events precipitated your decision to seek treatment?

What are your specific goals for treatment?

Psychological History
Please describe any major events you have struggled with (divorce, moving, birth of a sibling, loss, abuse, illness, etc.). Please include the dates the events occurred:

Have you ever had a suicide attempt?  Yes No
Are you currently having suicidal thoughts?  Yes No
Have you ever had thoughts of suicide, made a plan, or attempted suicide?  Yes No
If yes, please describe (specify date and reason):

Do you experience recurrent thoughts or repeated behaviors that you cannot control?  Yes No

Current mental health symptoms:

 Anger
 Anxiety
 Depression
 Mood Swings
 Obsessive Thoughts

Other:

Do you have any eating issues, current or past?  Yes No

Do you have any alcohol-, substance-, and/or depencency-related issues?  Yes No
If yes, please describe the choice of substance, when you first noticed the substance use, usage patterns and frequency, and how the substance was administered. Include cigarette use:

Is there a family history of drug or alcohol abuse?  Yes No

Please list any legal issues including charges, convictions, misdemeanors, felonies, probation, and current status:

Is there a family history of mental illness, including depression or anxiety?  Yes No

Current Therapist:
Name:
Phone:
Email:

Medical Information:
Family Doctor
Provider:
Location: Dates:

Please list any prescription and/or over-the-counter medications you are currently taking (include dosage, prescribing physician and their phone number, and the reason):

Please describe any pertinent medical/physical information that might inhibit physical activity:

Allergies:
 Yes No

Please list any allergies (food, medication, environmental, etc.), how it’s activated, and what happens:

Please list any pertinent family medical history: