THE NEW ALPHA WELLNESS CENTER | CONFIDENTIAL ADMISSIONS ASSESSMENT

THE NEW ALPHA WELLNESS CENTER | CONFIDENTIAL ADMISSIONS ASSESSMENT
THE NEW ALPHA INITIAL RECOVERY ASSESSMENT
Confidential Admissions Document
RESTORING LIVES. REBUILDING HOPE. RENEWING PURPOSE.
Applicant Name:

First NameLast Name
Date Started:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Completed By:
Every New Beginning Starts With Hope.

THE NEW ALPHA WELLNESS CENTER | CONFIDENTIAL ADMISSIONS ASSESSMENT
00 Welcome
Thank you for taking this important first step.

At The New Alpha Wellness Center, we believe recovery begins with courage, dignity, and hope. This assessment helps our Admissions Team understand the applicant's immediate needs, personal history, strengths, and goals so we can determine whether New Alpha may be an appropriate next step.

Please answer honestly and as completely as you can. If you do not know an answer, write "unknown." If a question does not apply, write "N/A." You may pause and return to the assessment if you need more time or information.
CONFIDENTIALITY & PURPOSE
The information collected through this assessment will be used to evaluate the applicant's needs and assist the Admissions Team in determining an appropriate level of care. Information will be handled in accordance with applicable privacy requirements. Completing this assessment does not guarantee admission and does not replace an in-person medical, psychiatric, or emergency evaluation.
Before You Begin
Current medication list Emergency contact information
Insurance information, if applicable Treatment history, if applicable
If the applicant is in immediate danger, experiencing a medical emergency, or at risk of harming self or others, call 911 or go to the nearest emergency department.
Person completing this assessment

First NameLast Name
Relationship to applicant
Best phone number
Format: (000) 000-0000.
Best email address
example@example.com

THE NEW ALPHA WELLNESS CENTER | CONFIDENTIAL ADMISSIONS ASSESSMENT
01 Applicant Information
Tell us who the applicant is and how best to make contact.
Legal name

First NameLast Name
Preferred name

First NameLast Name
Date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Pronouns (optional)
Marital status
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary phone
Format: (000) 000-0000.
Email address
example@example.com
Preferred contact method
Best time to contact
Contact permission
Emergency Contact
Name

First NameLast Name
Relationship
Phone number
Format: (000) 000-0000.
Email address
example@example.com
Referral Information
Referral source
Referral source name / organization

Rows	Substance	Frequency	Typical amount	Last use
1
2
3

Rows	Medication	Dose	Frequency	Reason / Prescriber
1
2
3
4

THE NEW ALPHA WELLNESS CENTER | CONFIDENTIAL ADMISSIONS ASSESSMENT

THE NEW ALPHA INITIAL RECOVERY ASSESSMENT

Confidential Admissions Document

THE NEW ALPHA WELLNESS CENTER | CONFIDENTIAL ADMISSIONS ASSESSMENT

00 Welcome

Before You Begin

01 Applicant Information

Emergency Contact

Referral Information

02 Substance Use History

Primary substance of concern

Withdrawal & Overdose

Previous Substance Use Treatment

03 Mental & Behavioral Health

Safety Screening

04 Medical Information

Current Medications