Personal Information

First name

Last name

Birthday

Month

Day

Year

Address

Phone

Gender

Male

Female

Ethnicity

Marital Status

Do you have children? If so, tell how many and if you have custody.

If female, are you pregnant?

Yes

No

What is your highest level of education?

Referral Information

(If self-referred, please answer this section with "N/A.")

Name of referral agency:

Contact person (name and email):

Agency address:

Agency phone number:

History of Substance Abuse

Please list all drugs used in the last 30 days along with their routes of administration (oral, smoke, inhalation, IV, etc.). Include how much you used each time, how many times the drug was used, and how old you were when you began using that drug.

Primary drug of choice:

Secondary drug of choice:

Have you ever used a needle?

Yes

No

If yes, how recently did you use a needle?

Have you used benzodiazepines in the last 30 days?

Yes

No

Do you use tobacco?

Yes

No

If yes, please indicate how you use tobacco.

Smoking

Dipping

Vaping

Chewing

Treatment History

Have you previously been in treatment at Shalom?

Yes

No

If so, when?

Please list any other treatment programs in which you were enrolled, along with the date of your stay. Indicate for each if you graduated.

Do you have a support system that fosters recovery?

Yes

No

Not sure

Please indicate which of the following you attend regularly:

Support groups

Church

Bible studies

What is your religious preference?

Medical History

Please list any physical, medical, or dental problems.

Do you have health problems that would limit your ability to work? If so, please explain.

Have you received professional counseling and/or therapy for reasons other than substance abuse? If so, when and where?

Do you have any history of seizures or hallucinations? If so, please explain.

Have you ever attempted suicide? If so, how many times, and when was your most recent attempt? Were you using at the time of the attempts?

If you have made a suicide attempt, did you receive medical intervention?

Yes

No

Are you currently suicidal?

Yes

No

Has a medical professional diagnosed you with any of the following:

List all prescription medication you are currently taking. For each, indicate if you have a prescription.

List any prescription medication you took in the past and no longer use. Explain why you no longer use it.

Would you be able to have a thirty-day supply of medication at intake?

Yes

No

Legal History

Are you currently on probation or parole?

Yes

No

If you are on probation or parole, please provide the officer's name, phone number, and email address.

Have you been arrested in the past 30 days?

Yes

No

If you are court-ordered, what county ordered you here?

If you have active warrants, list the places where you have warrants.

List all prior convictions.

List upcoming court dates and where they are.

List the dates, places, and charges associated with any incarcerations.

Are you a registered sex offender?

Yes

No

If yes, what level?

Do you have any holds, waivers, or detainers?

Yes

No

Financial Information

Please list any sources and amounts of income.

What is your occupation?

Are you able to pay a $500 intake fee?

Yes

No

If you are on disability, how much is your monthly benefit?

List all legal financial obligations such as child support, fines, fees and restitution that you owe.

Agreement and Consent

I hereby declare that all information in this form is true and complete to the best of my ability. I understand that my answers are confidential and will be used by Shalom Recovery Centers to determine the best plan of treatment for me. I acknowledge that Shalom Recovery Centers may contact me, my probation officer, my prior treatment facilities, or any other contacts given on this form.

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