Intake Form | The Intervention Experts

Intake Form

Date of first call
Cell Phone
Home Phone / Okay to call?
E-mail
Address
State
Name of caller
Relationship to person they are calling about
Person’s name they are calling about
Drug of Choice
Amounts using
Other substance’s using
Length of time using substances
In need of detox?
History of Withdrawal?
Dual Diagnosis /concerns
List of all known Medications / length of time prescribed and by whom
Any history of suicide ideation / attempts
History of depression
History of Violence / when / with whom
Guns or other weapons in the house or on person
Prior Tx. / Interventions?
Any length of sobriety following Tx.
Legal History
Any up-coming court dates
Is person currently on Probation? If so name/Number of probation officer
Any Outstanding Medical issues
Name of Medications
Any History of Trauma / accidents
Married / Divorced / Separated
Number of Children / ages
Key Intervention team members / Relationship to Client / phone numbers
Who Referred Family to Palm Beach Intervention?
Treatment Center Recommendations
Who will complete Intake for TX. Center
Bed Availability / Date of admission?
Intervention Planning Date
Deposit Sent?
Travel Planning

Fax the completed form to: 772.545.0635

Call Us Now at:
561.373.6203

For a Confidential, No Obligation 15-Minute Consultation.

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