Client Registration Client RegistrationName *Date of Birth *Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeEmail Address *PhoneName/Phone Number of Emergency Contact:List all drugs used currently and in the past:AlcoholAge First UsedQuantity/UsageDate of Last UseMarijuanaCocaineBenzosOpiatesHeroinCrystal MethOtherNegative Consequences for Drinking/Using (please fill out where applicable):FinancialLoss of Home or Vehicle(s)Professional -are you currently unemployed due to your addiction?LegalDUI/Public Intoxication?Felony Convictions/Date(s)?Date of infraction:Currently undergoing court proceedingsNature of conviction:Currently on probation or pending charges?FamilySingleMarriedSeparated from spouseChildren *YesNoHow many? *Do you have parental rights/relationship with your children or have you been separated either by family intervention or court order?Are you currently under the care of a mental health professional?YesNoPlease list any inpatient/outpatient treatment you have received?Have you ever been diagnosed with bipolar disorder, PTSD, or Depression?YesNoIs there a history of Addiction in your family (please explain) *MaternalPaternalDo you currently attend AA/NA or any other 12-step recovery program *YesNoDo you have a sponsor? *YesNoDo you suffer from any serious health issues:MEDICATIONDOSAGEI certify that the information I have provided above is true and correct to the best of my knowledge and I give permission for any necessary inquiries to verify the information, and hereby acknowledge and understand the purposes for which this information is needed. I certify and agree to immediately update any changes to this information as they occur, especially and including medications, diagnoses, psychological and medical conditions, and personal information, as long as I am receiving care as a clientBy *Start signing your signature hereYour browser does not support e-Signature field.On *I have read the HIPPA Privacy Statement and agree to it.Send Message