GUEST INTAKE INTERVIEW Today's Date * MM DD YYYY Participant Name * First Name Last Name Email * Phone * (###) ### #### Ethnicity DOB * Referral Source * Sober Date * MM DD YYYY Emergency Contact * First Name Last Name CRIMINAL BACKGROUND Do you have any pending charges? * Yes No If so, what charges? Have you even been convicted of a crime? Yes No If so what charges? Are you on probration or parole? * Yes No If so, officers name. Officers Phone (###) ### #### DRUG & ALCOHOL HISTORY Age of first use * Do you use tobacco? * Yes No Do you have a history of trauma? * Yes No History of substance abuse in family? * Yes No Do you have a history of mental illness in your family? * Yes No Have you been diagnoised for mental illness? * Yes No If so what was the diagnosis? * Are you currenty taking medication? * Yes No Medication #1 Please include name of medication and dossage. Medication #2 Please include name of medication and dossage. Medication #3 Please include name of medication and dossage. Name Of Most Recent Treatment Facility * Date Released * MM DD YYYY Treatment Contact Name * Treatment Contact Phone Number * (###) ### #### Emergency Contact Phone * (###) ### #### Name First Name Last Name Emergency Contact Number * (###) ### #### Thank you!