• Springboard Pre-Admissions Application

    Personal Information
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Gender*
  • Ethnicity*

  • Pre-Admission Screening Questions

  • Is this your first time to seek treatment or have you recently relapsed after being in treatment?*
  • Were any of these successful completions?*
  • Do you find yourself having to drink/use larger amounts or are you drinking/using longer than intended?*
  • Have you had a desire to stop or tried to stop using/drinking unsuccessfully?*
  • Are you spending a great deal of time obtaining and/or using a particular substance or struggling to recover from the effects of recent use? (ex: seeing multiple doctors and/or driving long distances)*
  • Do you have an intense desire or strong craving for your substance of choice?*
  • Is your use resulting in a failure to fulfill major obligations at work, school, or home? (ex: repeat absences, suspension, or neglect of children/household)*
  • Do you continue to use despite problems caused or made worse by the effects of your use? (ex: arguing with spouse, physical fighting, etc)*
  • Are important activities given up or reduced because of substance use?*
  • Have you continued to use in hazardous situations? (ex: driving a vehicle or operating machinery under the influence)*
  • Do you continue to use despite physical or psychological problems that are caused by or made worse by use of the substance? (Ex: drinking despite knowing an ulcer is made worse by alcohol)*
  • Do you have an increased tolerance to the effects of a substance or are you experiencing diminishing effects with use of the same amount?*
  • Do you have to drink or use to avoid withdrawal symptoms?*

  • Risk Assessment

  • Have you thought about or attempted suicide in the past year?*
  • Are you currently having thoughts of harming yourself?*
  • Have you experienced any thoughts of wanting to harm or kill someone else in the past year?*
  • Are you currently experiencing thoughts of wanting to harm or kill someone?*

  • Substance Abuse History

    • Substance #1 (alcohol, meth, heroin, etc.) 
    • Substance #2 (alcohol, meth, heroin, etc.) 
    • Substance #3 (alcohol, meth, heroin, etc.) 
    • Tobacco Use 

    • Tobacco Use

    • Do you currently use tobacco products?*

    • Medical History

    • Have you ever been diagnosed with a mental disorder such as depression, ADD, Bi-Polar, PTSD, etc...*
    • Do you have any medical conditions?*
    • Any seizures (drug induced)?*
    • Have you had any blackouts/DT's?*
    • Have you ever been on Anti-Craving medications such as Vivitrol or Naltrexone?*
    • Which one?*
    • Would you be willing to try them again?*
    • Are you currently taking or have been on Suboxone or Methadone maintenance? **The Springboard Center does not offer maintenance programs for these***

    • Other Questions

    • Have you ever served in the United States Military?*
    • If so, which branch?*

    • Financial Questions

    • The cost of treatment depends on the level of care required and the method of payment. In order for us to provide you with an accurate estimate, please let us know if you will be utilizing insurance benefits or if you will be private pay.*
    • Primary Insured Date of Birth
       - -
    • Is primary insured also the patient?
    • Format: (000) 000-0000.
    • Type of Insurance Plan*
    • Do you work in the oilfield?*
    • Total Household Annual Income. This is NOT used to determine your fee for services. This is ONLY used to determine the percentage of indigent/needy clients that we help.*
    • How did you hear about us?*
    • Should be Empty: