New Beginnings Questionnaire
Agency Referring the Client
Agency Name
Phone Number
Contact Email
example@example.com
Name of the Individual
*
First Name
Last Name
Client's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Sex:
*
If Female, Possible Pregnancy:
Yes No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Have you been in First Stop Recovery previously?
*
YES
NO
Drug & Alcohol Use History
*
Date of Last Use
*
-
Month
-
Day
Year
Date
Length of Use
Stairs Ok
Yes
No
Amount Used
Detox History and Prior Treatment
*
Motivating Factors for Seeking Treatment
*
Suboxone Use:
*
Yes
No
If Yes to Suboxone use: Use History, How Long
*
Diagnosed Medical Conditions, Allergies
*
Medications
*
Seizures:
*
Yes
No
If yes to seizures, the last Occurring Date: Due to Substance use: Yes/No
If Medical Seizures: Do Seizures Occur While Taking Medications
Yes
No
If Yes to Medical Seizures: Are you Taking Prescribed Meds Daily:
Yes
No
Mental Health History
*
Suicidal Ideation:
*
Yes
No
If Yes to Suicidal Ideation: Please Specify Suicidal History
History of Cutting
*
Yes
No
If Yes to Cutting: Last Cutting Occurrence
-
Month
-
Day
Year
Date
Are You A Registered Violent or Sexual Offender
*
Yes
No
Pending Legal Concerns:
*
Yes
No
If Yes to Legal Concerns: Please Specify
Open Wounds/History of MRSA:
*
Yes
No
Ambulation/Disabilities
Yes
No
Are you involved with 12-step programs?
*
YES
NO
If yes, do you have a sponsor?
*
YES
NO
N/A
Enter Sponsor Contact Information: Name, Phone and Email
*
May we contact your sponsor?
*
YES
NO
Will discuss with sponsor first
Preferred Bed Date and Time of Admission:
Upload Identification If You have
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*
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