Springboard Pre-Admissions Application
Personal Information
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Social Security Number
*
Email
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
*
Female
Male
Other
Ethnicity
*
White / Caucasian
Hispanic / Latino
Black / African American
American Indian
Asian
Other
Pre-Admission Screening Questions
Is this your first time to seek treatment or have you recently relapsed after being in treatment?
*
First time seeking treatment
In treatment previously
Provide treatment experiences
*
Include names of treatment centers and timeframe(s) attended
Were any of these successful completions?
*
Yes
No
Why are you currently seeking treatment?
*
Do you find yourself having to drink/use larger amounts or are you drinking/using longer than intended?
*
Yes
No
Please explain
Have you had a desire to stop or tried to stop using/drinking unsuccessfully?
*
Yes
No
Please explain
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)
*
Yes
No
Please explain
Do you have an intense desire or strong craving for your substance of choice?
*
Yes
No
Please explain
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)
*
Yes
No
Please explain
Do you continue to use despite problems caused or made worse by the effects of your use? (ex: arguing with spouse, physical fighting, etc)
*
Yes
No
Please explain
Are important activities given up or reduced because of substance use?
*
Yes
No
Please explain
Have you continued to use in hazardous situations? (ex: driving a vehicle or operating machinery under the influence)
*
Yes
No
Please explain
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)
*
Yes
No
Please explain
Do you have an increased tolerance to the effects of a substance or are you experiencing diminishing effects with use of the same amount?
*
Yes
No
Please explain
Do you have to drink or use to avoid withdrawal symptoms?
*
Yes
No
Please explain
Risk Assessment
Have you thought about or attempted suicide in the past year?
*
Yes
No
Formal attempt or just thoughts?
*
Please Select
Formal attempt
Just thoughts
If there was a formal attempt, how did you attempt?
*
Are you currently having thoughts of harming yourself?
*
Yes
No
If yes, have you made a specific plan to harm yourself or commit suicide?
*
Have you experienced any thoughts of wanting to harm or kill someone else in the past year?
*
Yes
No
If yes, was there a plan?
*
Are you currently experiencing thoughts of wanting to harm or kill someone?
*
Yes
No
If yes, please explain
Substance Abuse History
Substance #1 (alcohol, meth, heroin, etc.)
Substance
*
How do you use this substance?
*
Amount
*
Frequency
*
Duration of Current Use (How long have you been using?)
*
Date of Last Use
*
Age of First Use
*
Substance #2 (alcohol, meth, heroin, etc.)
Substance
How do you use this substance?
Amount
Frequency
Duration of Current Use (How long have you been using?)
Date of Last Use
Age of First Use
Substance #3 (alcohol, meth, heroin, etc.)
Substance
How do you use this substance?
Amount
Frequency
Duration of Current Use (How long have you been using?)
Date of Last Use
Age of First Use
Tobacco Use
Tobacco Use
Do you currently use tobacco products?
*
Yes
No
Medical History
Have you ever been diagnosed with a mental disorder such as depression, ADD, Bi-Polar, PTSD, etc...
*
Yes
No
If yes, please explain
*
Do you have any medical conditions?
*
Yes
No
If yes, please explain
*
Any seizures (drug induced)?
*
Yes
No
Please Describe (if caused by detox, please disclose here)
*
Have you had any blackouts/DT's?
*
Yes
No
Please describe
*
Have you ever been on Anti-Craving medications such as Vivitrol or Naltrexone?
*
Yes
No
Which one?
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Naltrexone
Vivitrol
Other
Would you be willing to try them again?
*
Yes
No
Are you currently taking or have been on Suboxone or Methadone maintenance? **The Springboard Center does not offer maintenance programs for these**
*
Yes
No
If yes, please tell us your last use and the dosage amount
*
Other self reported medications
*
Other Questions
Have you ever served in the United States Military?
*
Yes
No
If so, which branch?
*
Army
Navy
Air Force
Marines
Coast Guard
Space Force
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.
*
Insurance
Private Pay
Primary Insured Full Name
Primary Insured Social Security Number
Primary Insured Date of Birth
-
Month
-
Day
Year
Date
Is primary insured also the patient?
Yes
No
Insurance Provider
Provider's Phone Number
Please enter a valid phone number.
Group Number
Identification Number
Type of Insurance Plan
*
HMO
PPO
Other
Employer
*
Position
*
Do you work in the oilfield?
*
Yes
No
Including yourself, how many people are in your household?
*
Don't forger to count yourself.
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.
*
$0 to $15,460 20% of Area Median Income
$15,461 to $23,200 30% of Area Median Income
$23,201 to $30,920 40% of Area Median Income
$30,921 to $38,650 50% of Area Median Income
$38,651 to $50,100 60% of Area Median Income
$50,101 to $61,850 80% of Area Median Income
Other
Additional Monthly Income (child support/alimony)
*
Total Combined Monthly Expenses.
*
How did you hear about us?
*
TV Commercial / News
Radio Commercial
Social Media (Facebook, Instagram, YouTube)
Linked In
AA Member
Doctor / Medical Clinic
Other
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