RPR Intake Form MD

Intake Form

Complete this form to begin services with Renew Path Recovery. Your information is confidential and will help us provide the best care.
Client Information

Please provide your personal and contact details.
First Name
Last Name
Suffix
Date of Birth

MonthDayYear
Date
Social Security Number
Sex
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Best Phone
Appointment Reminders Preference
Marital Status
Sexual Orientation
Ethnicity
Race
Preferred Language
Religion
Veteran Status
Native American
Disability
Family Size
Employment Status
Annual Household Income
School or Employer
Emergency Contact
Emergency Contact Full Name

First NameLast Name
Relationship to Patient
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Insurance
Primary Insurance
Member ID / Policy Number
Group Number
If you DO NOT have insurance: We may assist you with Emergency Medicaid (EVS). Did you need us to apply for you?*
Safety Screening
Are you currently experiencing thoughts of self-harm?
Are you currently experiencing thoughts of harming others?
Do you have any current safety concerns?
Substance Use History
Are you currently using substances (alcohol, drugs)?
If yes, please list your substance use of choice.
Route of use (oral, smoking, etc)
Age of first use
Last time used

MonthDayYear
Date
Frequency and quantity
Mental Health History
Have you ever received a mental health diagnosis?
If yes, please specify the diagnosis.
Are you currently taking any medications?
If yes, please list them.
Have you ever been hospitalized for psychiatric reasons?
If yes, please list when.
Additional Info
Referral Source
Presenting Problem / Reason for Seeking Services
What services are you interested in?
Consent to Services and Communication
Release of Information
Should be Empty:

Intake Form

Client Information

Emergency Contact

Primary Insurance

Safety Screening

Substance Use History

Mental Health History

Additional Info