Quick Admit Form for Professional Referents

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Professional Referents
Quick Admission Form
Professional Outreach Staff
Daniel Hogue
Barbara Gale
Jack Bloomfield

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Joint Commission National Quality Approval

National Association of Addiction Treatment Providers

Name of person filling out this form: *
Relationship to patient:
Phone Numbers - Only list the numbers that you can be contacted on – if you would like to contact us instead, do
Home Phone:
Cell Phone:
Address:
Is this an intervention:	Yes No
If yes, are you working with an intervention?	Yes No
If yes, name interventionist:
PATIENT INFORMATION
Name of patient: *
Marital Status:
Children:
Patient Address:
The individual I am concerned with is having a problem with: *	Alcohol Other / Drugs
Has the patient had prior treatment for alcohol or other drugs?	Yes No Unkown
If yes, please specify:
Has the patient been hosplitalized within the past 6 months? *	Yes No Unknown
Does the patient have any physical medical issues? *	Yes No Unknown
Is the patient taking any special medications?	Yes No Unknown
If yes, please specify:
Has the patient had:
Tuberculosis?	Yes No
If yes, please explain:
Hepatitis?	Yes No
If yes, please explain:
Pain Issues?	Yes No
If yes, please explain:
Does the patient have allergies?
Medications:
Environment:
Food:
Is the patient pregnant?	Yes No Unkown
Is the patient under the care of:	Psychiatrist Therapist/Counselor Psychologist Others Unkown
In the past year, has the patient:	Thought of suicide Planned suicide Attempted Suicide Unkown
Does the patient have any eating disorders?	Anorexia Bulimia None Unkown
In the past year, has the patient:	Expressed intention to harm another person Engaged in threatening behavior Harmed another person Received a notice for a restraining order
Who will be listed as the Emergency Contact:
Relationship to patient:
Home Phone:
Cell Phone:
Address:
Who will be the guarantor of this account:
Method of Payment: Wire Transfer (Call for Instructions) Payment for Medications: Prescription medications are an additional charge. If the patient has coverage for medications, please have them bring their pharmacy benefit card and a credit card to cover any co-payments or amounts not covered by the benefit card.
Name of Insurance:
ID Number:
Group Number:
Thank you for your application. An Intervention Counselor will contact you within 24 hours of form receipt to help you.

Quick Admit Form for Professional Referrent