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Treatment Interest Form
First Name
Last Name
Email
Phone
Do you plan to use insurance?
Yes
No
If yes please list (Insurance Company/ Member#/ Group#
Are you looking for help with Alcohol?
Yes
No
If yes (What drugs are you taking?)
Has your alcohol or drug use negatively affected one or more of your relationships?
Yes
No
Has your work or school performance ever suffered due to drinking or drug use?
Yes
No
Have you ever stolen alcohol or drugs… or money to pay for them?
Yes
No
Have you ever had “blackouts” or “flashbacks” as a result of drug use?
Yes
No
Do you have trouble falling asleep or staying asleep?
Yes
No
Has your family been neglected because of your use of drugs?
Yes
No
Has your family been neglected because of your use of drugs?
Yes
No
Do you ever have thoughts of harming others, and have you ever made a plan to do so?
Yes
No
Do you ever have thoughts of harming yourself, and have you ever made a plan to do so?
Yes
No
Are you considering treatment for substance abuse?
Yes
No
Are you considering treatment for alcohol?
Yes
No
Do you have any mental health issues that have been diagnosed?
Yes
No
Are you currently taking any medications? If yes, please list below:
Have you had medical problems (e.g., memory loss, hepatitis, convulsions, bleeding, etc.), if yes, please list conditions below:
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Home
Facilities
Hidden Oaks – Chatfield
Resolutions Healthcare – Kaufman
FSTR- Gun Barrel City
Treatment Options
Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP)
Inpatient
Philosophy
About Us
Team
Blog
Podcasts
Contact Us
FAQ’s
Menu
Home
Facilities
Hidden Oaks – Chatfield
Resolutions Healthcare – Kaufman
FSTR- Gun Barrel City
Treatment Options
Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP)
Inpatient
Philosophy
About Us
Team
Blog
Podcasts
Contact Us
FAQ’s
Facebook
