Date Submitted*
MM slash DD slash YYYY
Client Information
Applicant Name*
Gender*
Pronouns*
DOB*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Height*
Weight*
Parent/Guardian/Spouse Information
Primary Parent/Guardian or Spouse Name*
Relationship*
Parent/Guardian or Spouse DOB*
MM slash DD slash YYYY
Parent/Guardian or Spouse Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian or Spouse – Mobile phone*
Parent/Guardian or Spouse – Email*
How did you first hear about Red Oak Recovery^®? Please include any referral source names and contact information:*

Family Information
Is the applicant adopted?*
- Yes
- No
Does the applicant have any siblings?*
- Yes
- No
Please list all siblings and their ages:*
Have the applicant's siblings struggled with mental health or substance use?*
- Yes
- No
Please explain:*
Were there any complications during birth mother's pregnancy or delivery?*
- Yes
- No
Please explain:*
Placement Information
What specific events precipitated your decision to seek treatment?*
What are your specific goals for the applicant while receiving treatment?*
What would you describe as the applicant's strengths? (intellectually, artistically, socially, physically, etc)*
What would you describe as the applicant's weaknesses? (intellectually, artistically, socially, physically, etc)*
Do you have any plans for future placement?*

Treatment History
Outpatient Therapy or Programs, Residential or Inpatient Programs
Treatment Provider*
Treatment Provider Location*
Reason for placement/intervention and outcomes*
Add Additional Treatment Providers?*
- Yes
- No
Please include additional treatment provider name(s), location(s), and reason for placement and outcomes:

Psychological History
Please describe any major events the applicant has struggled with (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.), including the date the event occurred:*
Describe the ways in which the applicant expresses anger*
Has the applicant had any physical confrontations in the home or with others?*
- Yes
- No
Please describe in detail including dates, persons involved, and circumstances that induced the event:*
Has the applicant ever intentionally hurt themself?*
- Yes
- No
Please describe in detail (include date, reason, what was used, where on the body the self-harm occurred, if medical attention was needed, how many times it occurred, and/or for how long):*
Has the applicant ever had thoughts of suicide, made a plan, or attempted suicide?*
- Yes
- No
Please describe in detail (specify date, reason, if thoughts are active or passive, manipulation, and/or general history):*
Has the applicant ever run away?*
- Yes
- No
Please describe (specify date, how long applicant ran away for and where, if the applicant had contacted you, etc.):*
Does the applicant exhibit signs of anxiety, depression, mood swings, etc.?*
- Yes
- No
Please describe in detail with examples and dates when behaviors were exhibited:*
Does the applicant experience recurrent thoughts or repeated behaviors that they cannot control?*
- Yes
- No
Please describe in detail, and include dates:*
Does the applicant have a history of lying, stealing, vandalism, dealing drugs, and/or criminal activity?
- Yes
- No
Please describe in detail, and include dates:*
Has the applicant ever been charged with or convicted of sexual assault?*
- Yes
- No
Please include charge or conviction details, including type and approximate dates:*
Does the applicant have a history of eating issues, current or past?*
- Yes
- No
Please describe eating issues in detail, and include dates:*
Does the applicant have problems with isolation?*
- Yes
- No
Please describe problems with isolation in detail:*
Does the applicant have any alcohol, substance abuse, and/or dependency-related issues?*
- Yes
- No
Please describe alcohol, substance abuse, and/or dependency-related issues:*
Does the applicant need detox prior to coming to Red Oak Recovery^®? If so, explain:*
Has the applicant had any psychological testing?*
- Yes
- No
Please describe testing (including date(s)/reason(s):*
Have there been other addictive patterns (e.g. video games, TV, internet, sex, gambling)?*
- Yes
- No
Please describe other addictive patterns:*
Have there been legal problems?*
- Yes
- No
Please list any charges, convictions, misdemeanors, felonies, probation and current legal status:*
Is there family history of substance use or mental illness?*
- Yes
- No
Please describe family mental illness or substance use history:*

Medical Information
Applicant's most recent doctor and phone number:*
Has the client experienced any recent/current illnesses or injuries? If so, what follow-up care is required?*
Has the applicant ever had a seizure? If so, please provide dates and a detailed description of the event(s):*
Has the applicant had any head injuries, loss of consciousness, or concussions? If so, please provide dates and a detailed description of the event(s):*
Is the applicant currently taking any prescribed or over-the-counter medications? If so, provide details below.
Are there any known side effects of the medication(s)? If so, please describe:*
Please describe previous history of medication(s); have any medications worked/not worked in the past?*
Has the applicant struggled with medication compliance, especially in a treatment program? Please describe:*
Is the applicant currently taking any vitamins or supplements? If so, please describe:*
Describe any medical/physical information that might limit or impair tolerance for physical activity:*
Does the applicant have any dietary restrictions/preferences? If so, please describe, including the reaction:*
Does the applicant have allergies or asthma? If so, provide details below:*
Does the applicant carry an inhaler or epinephrine pen? If so, please list name/type of inhaler:*
Has the applicant ever been hospitalized for allergies/asthma? If so, please describe (include date/reason):*
List of Medical Conditions / Abnormalities:
Does the applicant currently have or ever had any of the following?
- Allergies
- Anaphylactic shock
- Anemia
- Ankle problems
- Anorexia/bulimia
- Appendicitis
- Arm problems
- Arthritis
- Asthma
- Back problems
- Bedwetting
- Bladder/kidney problems or infection
- Bleeding disorder
- Bone condition
- Bowel problems
- Broken bones
- Cancer
- Chest pains
- Chronic cough
- Circulation issues
- Colds (frequent)
- Constipation
- Cysts/tumors
- Dermatitis
- Diabetes I/II
- Diarrhea
- Difficulty walking or lifting
- Ear infections
- Endocrine problems
- Excessive sweating
- Fainting/dizziness
- Family history of heart disease
- Foot problems
- Frequent colds/sore throats
- Frequent heartburn
- Frequent muscle cramps
- Frequent shortness of breath
- Frostbite
- Gas/bloating
- HIV/AIDS
- Head traumas
- Headaches/migraines
- Hearing impairment
- Heart problems/murmurs
- Hepatitis A/B/C
- Hernia
- High blood pressure
- Hypoglycemia
- Intolerance to cold
- Intolerance to heat/overheats easily
- Irregular heartbeat
- Joint injuries
- Kidney problems
- Knee problems
- Leg problems
- Liver problems
- Lung infections
- Medical equipment or devices
- Meningitis
- Menstrual problems/ heavy bleeding
- Mononucleosis
- Motion sickness
- Obesity
- Other
- PMS - severe symptoms
- Pneumonia/bronchitis
- Pregnancy
- Recurrent injury/surgery
- STDs
- Scoliosis
- Seizures/epilepsy
- Shoulder problems
- Skin diseases/problems
- Sleepwalking
- TB - Positive test
- TB - Recent exposure
- TB - Tuberculosis
- Thyroid problems
- Ulcers
- Unexpected weight loss
Please describe any checked item in full detail, including dates, symptoms, and thorough explanation:*
*
- By checking this box, I am attesting that all of the above medical conditions have been reviewed and that the applicant has never experienced any of the boxes left unchecked.
Please list any pertinent medical history in the applicant’s family:*

Insurance Information
My insurance information has already been submitted to the Admissions Team.*
- Yes
- No
Primary Insurance Company*
Group number*
Policy number*
Policyholder's name*
Policyholder's DOB*
MM slash DD slash YYYY