• 1. PATIENT INFORMATION

  • MAILING ADDRESS (IF DIFFERENT FROM ABOVE)

  • VEHICLE INFORMATION (REQUIRED IF DRIVING TO TREATMENT)

  • 2. EMPLOYER INFORMATION IF INSURED

  • 3. INSURANCE INFORMATION






  • TO BE COMPLETED BY PATIENT And/Or MINOR'S FAMILY
























  • 1. LEGAL

  • HAVE YOU EVER BEEN ARRESTED FOR ANY OF THE FOLLOWING?




































































































  • *REMINDER: RELEASE TO BE SIGNED BY OFFICER.












  • 2. EMPLOYER


































  • *REMINDER: RELEASE TO BE SIGNED BY OFFICER.














































































  • 3. HEALTH


















  • 4. FAMILY
























  • WHO WILL ATTEND FAMILY PROGRAM?












  • 5. GENERAL



































































  • 6. SPIRITUAL ASSESSMENT













































  • 7. DISCHARGE PLANNING

  • Hill Alcohol and Drug Treatment Health questionnaire

  • SECTION 1 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

  • SECTION 2 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

  • SECTION 3 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

  • SECTION 4 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

  • SECTION 5 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

  • SECTION 6 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

  • SECTION 7 PLEASE ANSWER YES OR NO. IF YES, PLEASE GIVE DATES AND DETAILS.

  • SECTION 8 DETOX RISK ASSESSMENT

  • Last date that substance was used?
  • 36. Are you currently experiencing any of the following?

  • SECTION 8 FAMILY MEDICAL HISTORY

  • 37. Has a 1st degree relative had the following:

  • If yes to any of the above, please complete the following:

  • Signatures & Dates

  • EARLY TERMINATION AGREEMENT

  • acknowledge that the assessme·nt and/or doctor visit fees(where applicable) are included when I start the Hill Alcohol and Drug Treatment program. Should I decide not to come into the program, I understand that I will be charged to cover the costs of the services rendered at the rates shown below.

    Dr. Visit
    Price: $200.00

    Assessment/Intake Fee
    Price: $300.00




  • Should be Empty: