RPR Intake CA

Renew Path Recovery Intake

Standard online intake form for the California IOP/PHP program. Complete all applicable sections and include all collected information and signatures.
Program Level of Care
Client Demographics
Full Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
Date
Social Security Number
Gender
Race / Ethnicity
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Education Level
Employment
Referral Information
Referred By
Substance Use History
Substances Used (Past or Current)
Primary Substance(s)
Route of Use
Frequency & Quantity
Age of First Use
Date of Last Use

MonthDayYear
Date
Previous Treatment Attempts
History of Overdose
Number of Overdoses
Mental Health History
Prior mental health diagnosis
If yes, prior mental health diagnosis details
Interested in therapy services
Current symptoms (past 30 days)

Other
Psychiatric medications
Psychiatric hospitalization history
Psychiatric hospitalization details
Legal History
Arrests
Convictions
Incarceration
Probation/Parole
PO Name/Phone
Pain Assessment
Pain Location
Pain Type

Other
Pain Scale (0–10)

0

1

2

3

4

5

6

7

8

9

10

0 is No pain, 10 is Worst pain
Suicide Risk Screening
Past 2 weeks - Wish to be dead
Past 2 weeks - Thoughts of death
Past 2 weeks - Suicidal ideation
History of suicide attempts
Suicide attempt details
Signatures
Client Name
Client Signature
Client Signature Date

MonthDayYear
Date
Should be Empty:

Renew Path Recovery Intake

Client Demographics

Referral Information

Substance Use History

Mental Health History

Legal History

Pain Assessment

Suicide Risk Screening

Signatures