Substance Abuse (90 Days for Men and Women ) Form

Full Name

Gender

Date of Birth

Contact Number

Email Address

Address

Emergency Contact:

Full Name

Relationship to Participant

Contact Number

Email Address

Address

Medical Information:

Are you currently under the care of a physician or mental health professional?

List any medical conditions or allergies we should be aware of:

Are you currently taking any medications?

Have you ever been hospitalized for mental health reasons?

Do you have any dietary restrictions or preferences?

Do you have any physical limitations or mobility concerns we should be aware of?

Past Treatment History

Motivation for Participation:

Additional Comments or Concerns:

Signature

I hereby certify that the information provided above is true and accurate to the best of my knowledge.

Date