CANDIDATE INTAKE QUESTIONNAIRE

Date:

Date

Name:

First NameLast NameNick Name

Height:

ft.in

Weight:

lbs.

Date of Birth:

Date

Age:

MaleFemale

Contact Phone:

Format: (000) 000-0000.

YesNo

Mailing Address:

City:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email Address:

example@example.com

Emergency Contact Name:

Relationship:

Email Address:

example@example.com

Phone:

Format: (000) 000-0000.

How did you find Avante?

Primary Physician:

Phone:

Format: (000) 000-0000.

Date of last physical exam:

Date

Current Psychologist/Therapist:

Phone:

Format: (000) 000-0000.

YesNo

Issuing Country?

Date of last physical exam:

Date

What are you seeking help with?

List any current illness/health problems:

List any diagnosed medical conditions in the last five (5) years:

1.

Approx. Date:

Date

2.

Approx. Date:

Date

3.

Approx. Date:

Date

List all previous substance abuse treatment-including In-Patient, I.O.P., Supervised Detox, Counseling/Therapy, etc:

List all currently prescribed medications and over-the-counter drugs (including vitamins, inhalers, etc.):

List all of your known allergies (include medications, foods, airborne allergens, etc.):

YesNo

If so, explain:

YesNo

Month:

Year:

NormalAbnormalUnknown

YesNo

If yes, what form of exercise?

DailyWeeklyMonthly

YesNo

DailyWeeklyMonthly

YesNo

When was your most recent seizure or DT episode? (please be specific)

YesNo

If yes, how much/often?:

YesNo

If yes, how much/often?:

What recreational and/or street drugs do you use?

1. Drug

1. Amount

1. Last Use

2. Drug

2. Amount

2. Last Use

3. Drug

3. Amount

3. Last Use

4. Drug

4. Amount

4. Last Use

5. Drug

5. Amount

5. Last Use

6. Drug

6. Amount

6. Last Use

What other recreational and/or street drugs have you used in the past but not currently using?

Do you have any medical issues at all that have not been covered??

CLIENT CONSENT AND RELEASE

I acknowIedge that I have received, have read (or have had read to me) and understand the information provided to me by The Avante Institute regarding the therapy that I am considering. Further, that I have had aII of my questions thoroughIy answered.

AccordingIy, I do hereby seek and consent to taking part in the recovery oriented system of care provided by The Avante Institute, it´s contractors, sub-agents and/or empIoyees and I am entering into this treatment without coercion, promise, demand or threat. I have personally completed the medical questionnaires and intake forms and have provided the Avante Institute with a completely thorough and truthful account of my medical history, current and past prescription medication use, and current and past recreational drug and alcohol use.

It has been expIained to me that my faiIure to provide this compIete and truthfuI account couId affect the outcome of my treatment and may result in adverse heaIth consequences and/or death. I further recognize that my active participation in the program is necessary to receive the fuII benefit of the treatment being provided and I agree to engage in an active roIe in my recovery.

I understand that no promises have been made to me as to the anticipated resuIts of this treatment, behavioraI heaIth, counseIing, recovery coaching, case management, supportive services, mentoring or any other procedures that may be provided by The Avante Institute, it´s contractors, sub-agents and/or empIoyees.

I am aware that attendance as scheduled is required and that I may stop the course of treatment at anytime but all fees and costs are fully non-refundable and any outstanding balances will be required to be honored and settled with the Avante Institute.

My Signature below indicates that I understand and agree with all of the above statements."

Client Signature:

Printed Name:

CANDIDATE INTAKE QUESTIONNAIRE

PERSONAL INFORMATION

CONTACT INFORMATION

EMERGENCY CONTACT

REFERRAL

PHYSICIAN AND THERAPIST INFO

PASSPORT INFO

TREATMENT GOALS

PERSONAL MEDICAL HISTORY

CONFIDENTIAL CANDIDATE INTAKE QUESTIONNAIRE

PERSONAL MEDICAL HISTORY

PERSONAL MEDICAL HISTORY (Continued)