THE NEW ALPHA WELLNESS CENTER | COMPLETE CONFIDENTIAL ADMISSIONS ASSESSMENT

THE NEW ALPHA WELLNESS CENTER | COMPLETE CONFIDENTIAL ADMISSIONS ASSESSMENT

Please complete this assessment on your phone or device.
00 Welcome and Emergency Notice

Please complete this assessment on your phone or device.
RESTORING LIVES. REBUILDING HOPE. RENEWING PURPOSE. Every New Beginning Starts With Hope. Welcome. This assessment helps the Admissions Team understand immediate needs, history, strengths, and goals. Please answer as honestly and completely as you can; unknown and N/A are acceptable, and you may pause and return when needed. Confidentiality and Purpose: The information you provide will be used for initial admissions review and level-of-care consideration. Completing this form does not guarantee admission, and it does not replace an in-person medical, psychiatric, or emergency evaluation. Before You Begin: - Medication list - Emergency contact information - Insurance information, if applicable - Treatment history, if applicable
If you’re in immediate danger, call 911 or go to the nearest emergency department.
This form is not monitored continuously. 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.
01 Person Completing the Assessment
Are you the applicant?
Your name

First NameMiddle NameLast Name
Relationship to applicant
Best phone
Please enter a valid phone number.Format: (000) 000-0000.
Best email
example@example.com
Preferred contact method
Preferred contact time

Hour Minutes

AM/PM Option
Permission for contact methods
02 Applicant Information
Applicant Legal Name

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pronouns
Marital Status
Current Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Contact Preferences and Permissions

Leave detailed messages
Emergency Contact Name

First NameMiddle NameLast Name
Emergency Contact Relationship
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Referral Source
Referral Organization
03 Presenting Need and Admission Request
Reason for seeking help now
Services requested

Other
Desired admission date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Willingness to enter treatment
Immediate barriers to admission

Other
Recovery goals
04 Substance Use History
Primary substance
Age first used
Route of use
Typical amount used
Frequency of use
Duration or pattern of use
Date and time last used

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Hour MinutesAM/PM Option
History of overdose?
Additional substances used in the past 12 months

Other
Current withdrawal symptoms
History of severe withdrawal, seizure, or delirium tremens
Number of overdoses
Most recent overdose date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Naloxone previously administered or accessed
Previous treatment history
05 Mental and Behavioral Health
Current mental or behavioral health diagnoses
Mental or behavioral health treatment history
Current mental or emotional symptoms
Current therapist name
Current therapist phone number
Please enter a valid phone number.Format: (000) 000-0000.
Current psychiatrist name
Current psychiatrist phone number
Please enter a valid phone number.Format: (000) 000-0000.
Psychiatric hospitalizations or inpatient treatment history
This form is not monitored continuously. 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.
06 Medical Information
In the past 30 days, have you had thoughts of suicide or of hurting yourself?
Have you ever attempted suicide?
In the past 30 days, have you had thoughts of harming someone else, hallucinations, paranoia, severe confusion, or any current concern that you may not be safe?
Is there a current medical emergency requiring immediate attention?
Provide brief details, relevant dates, current plan or intent if applicable, access to means if applicable, and current safety supports.
Is the applicant currently pregnant or could pregnancy be relevant to care?
Current medical conditions

Other
Communicable disease or infection considerations for safe care

Other
Recent surgeries, hospitalizations, or emergency room visits
Mobility or accessibility needs

Other
Allergies and reactions
Primary care provider name
Primary care provider phone
Please enter a valid phone number.Format: (000) 000-0000.
Preferred pharmacy name
Preferred pharmacy phone
Please enter a valid phone number.Format: (000) 000-0000.
Can the applicant manage personal care independently?
Medical equipment or support devices in use

Other
Sleep needs

Other
Dietary needs or restrictions

Other
07 Current Medications
Are you currently taking any medications?
Medication List
If any medications are not taken as prescribed, please explain.
Where do you usually get your medications?

Other
Preferred pharmacy name (if applicable)
Preferred pharmacy phone number
Additional medication-related information
08 Family, Social, and Living Situation
Current living arrangement
How stable and safe is your current housing?
Who lives in your household?
Who are your main support people?

Other
Do you have any dependents who need regular care?
If yes, please describe childcare, caregiving, or support needs
Would you like family or support people involved in your care?
How do you usually get to appointments or services?

Other
Communication and language needs

Other
Cultural, spiritual, or personal considerations we should know about

Other
09 Education, Employment, and Military History
Highest level of education completed

Other
School or training program name
Current employment status

Other
Employer or organization name
Military or veteran status

Other
Discharge status, if applicable
Vocational, education, or career goals
10 Legal History and Court Requirements
This section is collected to support care coordination and treatment planning. It is not legal advice.
Are you currently involved with the legal system?
Current legal status

Other
Describe any current charges or court requirements
Next court date or hearing

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is treatment mandated or recommended by a court, probation, or parole officer?
Officer or caseworker contact information
11 Insurance and Financial Information
Do you have insurance coverage?
Primary insurer name
Member ID
Group number
Policyholder name

First NameMiddle NameLast Name
Policyholder relationship
Policyholder date of birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurer phone number
Please enter a valid phone number.Format: (000) 000-0000.
Upload front of insurance card

Cancelof
Upload back of insurance card

Cancelof
Do you have secondary coverage?
Payment arrangement
Permission to verify benefits
12 Strengths, Preferences, and Recovery Goals
What are your main strengths?
What has helped you in the past when you were making progress?
What are your current recovery goals?
What types of support or approaches do you prefer?

Other
Would you like spiritual or faith-based support included in your care?

Other
Do you need any accommodations or supports to participate fully in treatment?
What concerns or worries do you have about treatment or admission?
Is there anything else the admissions team should know?
13 Admission Readiness and Logistics
Preferred level of care, if known
Availability for admission
Transportation plan

Other
Documents available to bring

Other
Best phone number for scheduling contact
Please enter a valid phone number.Format: (000) 000-0000.
Placement is subject to clinical review and bed or program availability
14 Authorizations, Acknowledgements, and Signature
Accuracy acknowledgement
Permission to contact me about admission
Acknowledgement of limitations
Privacy notice acknowledgement
Optional consent for admissions coordination
Typed name
Relationship to applicant
Electronic signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

THE NEW ALPHA WELLNESS CENTER | COMPLETE CONFIDENTIAL ADMISSIONS ASSESSMENT

00 Welcome and Emergency Notice

01 Person Completing the Assessment

02 Applicant Information

03 Presenting Need and Admission Request

04 Substance Use History

05 Mental and Behavioral Health

06 Medical Information

07 Current Medications

08 Family, Social, and Living Situation

09 Education, Employment, and Military History

10 Legal History and Court Requirements

11 Insurance and Financial Information

12 Strengths, Preferences, and Recovery Goals

13 Admission Readiness and Logistics

14 Authorizations, Acknowledgements, and Signature