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Addiction Recovery Ministries, Inc. Client Information Form
Name: __________________________Date:_____________________Date of Birth: _________________Social Security Number____________________ (Do you have identification?) Yes_____ No____ If yes complete Identification: State ID_________________________________
Driver’s License_________________________ Are you a Are you homeless? ___________________________________ How did you become homeless? __________________________________________ ______________________________________________________________________ Family Contact Name: _______________________________________ Family Contact Address: ________________________________________________ Phone Number____________________________________________ What is your drug of Choice? ____________________________________________ When was the last time that you used? _____________________________________
What Happened?_______________________________________________________
Have you had a recent TB test? ___________________________________________ Where? ___________________________________ When? ____________________________________ Results? ___________________________________ Have you had a recent RPR at the Health Department? ______________________ Are you HIV positive? __________________________________________________ Are you on Social Security Disability? Yes____ No____ If yes what is the disability? ______________________________________________ How much do you receive? _______________________________________________ Do you have an employer? _______________________________________________ Last Employer? ______________________________________________________ Have you ever been in a treatment center? Yes___ No___ When? __________________________ Where? __________________________ How long did you stay clean? ____________________________________________ What happened? ______________________________________________________________________ _______________________________________________________________________________ How did you hear about ARM, Inc.?______________________________________ What do you expect from your stay with us? ______________________________________________________________________ ______________________________________________________________________ Do you currently have any legal problems? YES____NO____ If you answered YES, please explain._______________________________________ ________________________________________________________________ What City? Are you currently on Probation? YES____NO____ If you answered YES, explain what you are on probation for. _____________________________________________________________________ _____________________________________________________________________ ______________________________________________________________________________ If you answered YES, please provide Probation Officer’s Name; __________________________________________________ Probation Officer’s Phone #; ________________________________________________ Do you have any outstanding warrants or any pending cases against you? YES___NO___ If you answered YES, PLEASE Explain _____________________________________________________________________
_____________________________________________________________________ Number of children
Marital status_________________________ Educational level ______________________ Have you ever been arrested or imprisoned? Yes____ No____If yes, please explain the circumstances
________________________________________________________________________ ________________________________________________________________________ I, _________________________, am aware that any false information enteredon this questionnaire will result in my immediate discharge from the program.Resident’s Signature _____________________ Date___________Admitting Staff Signature ___________________Date_______ |
