Intake Information Form:

Intake Date:
Last Name:
First Name:
Email:
Middle Name:
Social Security Number:
Current Age:
Date of Birth:
Race:
Place of Birth:
Highest Grade Completed:
Drug of Choice:
Date Last Used:
Last Permanent Address/City/State/Zip:
Last Permanent Phone:
Athens Home?
Homeless Verification Signed, On File?
Permanent Home Address:
Permanent Home Phone:
Current Employer:
Empoyer's Address/Phone (if applicable)
Last Medical Checkup Date:
Reason for Last Medical Checkup:
Any Current Illnesses:
Previous Re-Hab Centers Name/Address/Date:
Any Physical Limitations:
If Yes to Physical Limitations, Please Describe:
Any Medications:
Last TB Test Date:
Last TB Test Site:
Read/Write Limitations:
If Yest to Rea/Write Limitations, Please Describe:
Referred By:
Disabled:
Disability Income:
Other Income:
Veteran:
Criminal History:
On Probation or Parole:
Do you owe any fees or fines:
PO Name/Address/Phone:
Do you have any cases/charges pending:
If Yes to Cases/Charges, Please Explain:
Child Support:
Child Support Amount (if applicable):
Case Worker:
Case Worker Name/Address/Phone (if applicable):
Sobriety Date:
   
EMERGENCY CONTACT INFORMATION
Name:
Phone:
City:
State:
Zip:
Relationship: