Preliminary Intake Assessment

Please fill out the form below.

Preliminary Intake Assessment Form
  • Applicant Information
  • Legal Information
  • Substance Use & Treatment History
  • Family & Relationship Background
  • Physical Health
  • Mental Health
  • Spiritual/Religion
    • Program Readiness

    Personal Information

    Name
    Name
    First Name
    Last Name
    Address
    Address
    City
    State/Province
    Zip/Postal
    Country

    Referring Institution

    Address
    Address
    City
    State/Province
    Zip/Postal
    Country

    Emergency Contact

    Name
    Name
    First Name
    Last Name
    Address
    Address
    City
    State/Province
    Zip/Postal
    Country

    Lawyer Contact

    Education/Work Experience

    Education
    Check the most relevant, or all that apply

    Sources of Funding for Treatment Services

    Checkboxes
    Check all that apply