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Intake
Contact
Home
About
Treatments
Dual Diagnosis
Schizophrenia
Bipolar Disorder
Trauma & Addiction
Depression
Alcohol Addiction
Drug Addiction
Opioid Addiction
Programs
Individual Therapy
Group Therapy
Family Counseling
Trauma Therapy
Medication Management
Admission
Intake
Contact
(928) 848-2358
Begin Your Journey
Home
About
Treatments
Dual Diagnosis
Schizophrenia
Bipolar Disorder
Trauma & Addiction
Depression
Alcohol Addiction
Drug Addiction
Opioid Addiction
Programs
Individual Therapy
Group Therapy
Family Counseling
Trauma Therapy
Medication Management
Admission
Intake
Contact
Home
About
Treatments
Dual Diagnosis
Schizophrenia
Bipolar Disorder
Trauma & Addiction
Depression
Alcohol Addiction
Drug Addiction
Opioid Addiction
Programs
Individual Therapy
Group Therapy
Family Counseling
Trauma Therapy
Medication Management
Admission
Intake
Contact
(928) 848-2358
Begin Your Journey
ViewPoint Admissions
Your journey to recovery begins with clarity.
Please complete both parts of our digital intake packet below. Your progress is saved automatically so you can pause and resume at any time.
BEGIN INTAKE PORTAL
CALL ADMISSIONS
"
*
" indicates required fields
Step
1
of
12
8%
Company
This field is for validation purposes and should be left unchanged.
Family History Questionnaire
Part 1 of 2 — Please provide information about the client and family.
Client & Contact Information
Please provide basic information. This will carry over to the next section.
Name
*
First
Last
Date
*
Phone
*
Email
*
Family History Questionnaire
Part 1 of 2 — Please provide information about the client and family.
Milestones & History
Growth & Development, School/Work, Substance Use History, Mental Health Timeline
*
Family History Questionnaire
Part 1 of 2 — Please provide information about the client and family.
Support System & Family
Significant People in Client's Life (positively and negatively)
*
Client's Strength and Weaknesses
*
Other Children in the Family
*
Family Members with Similar Issues
*
Family History Questionnaire
Part 1 of 2 — Please provide information about the client and family.
Illness & Legal History
Pre-Onset Behavior
*
Prior Hospitalizations / Treatment Admissions
*
Previous or Current Legal Issues
*
Family History Questionnaire
Part 1 of 2 — Please provide information about the client and family.
Loved One's Needs Assessment
Financial Services and Benefits Needs
*
Personal Hygiene Needs, Preferences, Goals
*
Activities of Daily Living
*
Leisure and Recreational Activities
*
Service Recomendations
Personal Grooming and Hygiene
Housekeeping
Budgeting
Banking
Patient Clinical Intake Form
Part 2 of 2 — Confidential patient intake questionnaire and disclosures.
Patient Goals
Let's align on what you would like to achieve from your treatment.
What are your treatment goals / what do you hope to achieve from your appointment?
Patient Clinical Intake Form
Part 2 of 2 — Confidential patient intake questionnaire and disclosures.
Symptom Checklist
Check any issues you are currently experiencing or have experienced in the past.
Depressed Mood
Irritability
Paranoia
Fatigue
Anger Problems
Hallucinations
Lack Of Enjoyment
Decreased Sleep Need
Eating Disorder
Decreased Sex Drive
Increased Sex Drive
Disorganized Thoughts
Hopelessness
Racing Thoughts
Homicidal Thoughts
Sleep Problems
Excessive Energy
Self Harm
Weight Change
Impulsivity
Marital Problems
Avoidance Behaviors
Thoughts Of Hurting Others
School Problems
Crying Spells
Excessive Guilt
Muscle Tension
Work Friend Problems
Lack Of Concentration
Anxiety Attacks
Legal Problems
Feelings Of Worthlessness
Obsessions Compulsions
Housing Problems
Memory Problems
Flashbacks
Physical Reactions Stress
Mood Swings
Nightmares
Gambling
Mania
Sexual Problems
Substance Abuse
Purging
Other Addictions
List other history or symptoms here...
Patient Clinical Intake Form
Part 2 of 2 — Confidential patient intake questionnaire and disclosures.
Suicide / Safety Risk Assessment
This is a required clinical screening section to help keep you safe.
Have you ever harmed yourself on purpose?
NO
YES
Have you ever assaulted anyone else?
NO
YES
Do you have thoughts of harming anyone else?
NO
YES
Do you have plans to harm anyone else?
NO
YES
Have you ever had feelings that you don't want to live?
NO
YES
FOLLOW-UP SAFETY QUESTIONS
Do you currently feel that you don't want to live?
NO
YES
Do you have a plan for suicide at this time?
NO
YES
Is the method readily available?
NO
YES
When was the last time you had thoughts of dying?
How often are these thoughts present?
Have you ever attempted suicide before?
NO
YES
If so, what was the method, and when did this occur?
Access to weapons in the home?
NO
YES
Patient Clinical Intake Form
Part 2 of 2 — Confidential patient intake questionnaire and disclosures.
Medical History & Medications
Please tell us about your Primary Care provider and any medications or medical conditions.
Primary Care Physician Name
PCP Phone Number
Date of Last Exam
Date of Last Labs
Allergies (Medication or Food)
Preferred Pharmacy (Name, Cross Streets)
Current Medications
Medication Name
Dosage
Reason for Taking
Prescribed By
Add
Remove
Current Over-the-Counter Supplements
Exercise Level (Frequency & Type)
Do you eat a healthy diet?
NO
YES
Medical illnesses / surgeries (please list and date)
History of head injury?
NO
YES
Provide head injury details (unconsciousness, date)...
History of seizures?
NO
YES
Patient Clinical Intake Form
Part 2 of 2 — Confidential patient intake questionnaire and disclosures.
Physical Symptoms Review
Select yes or no for each general physiological system review.
General (Fever, weight changes, fatigue)
NO
YES
Dermatologic (Rash, sensitivities)
NO
YES
Gastrointestinal (Diarrhea, constipation)
NO
YES
Cardiovascular (Chest pain, palpitations)
NO
YES
Genitourinary (Painful or frequent urination, impotence)
NO
YES
Musculoskeletal (Pain, injury, stiffness)
NO
YES
Eyes/Ears/Nose/Throat/Mouth (Vision, hearing, dental)
NO
YES
Hematological (Bruising, blood loss)
NO
YES
Respiratory (Shortness of breath, wheezing)
NO
YES
Other physical symptoms not listed
Current birth control?
NO
YES
Type of birth control
For Women Only
Date of last menses
Are you now pregnant?
NO
YES
Are you planning to get pregnant?
NO
YES
Patient Clinical Intake Form
Part 2 of 2 — Confidential patient intake questionnaire and disclosures.
Psychiatric Treatment & Substance History
Prior therapist or inpatient admissions.
PRIOR OUTPATIENT TREATMENT
Has patient had prior outpatient treatment?
NO
YES
Reason for Outpatient Care
Dates of Treatment
Provider Name
CURRENT THERAPIST/COUNSELOR
Therapist/Counselor Name
Phone Number
How often do you see them?
Prior Inpatient Treatment History?
NO
YES
INPATIENT ADMISSIONS
Date of Admission
Name of Facility
Location
Reason
Add
Remove
Substance Use History
Have you ever been treated for alcohol or drug abuse?
NO
YES
If yes, substance, when, and where?
Do you think you may have a problem with alcohol or drugs?
NO
YES
If yes, which ones?
How many days weekly do you drink alcohol?
Longest period of sobriety
History of IV use?
NO
YES
Substance Usage Details
Substance Name
Last Use Date
Amount
Frequency
Duration (Years)
Other Info
Add
Remove
Patient Clinical Intake Form
Part 2 of 2 — Confidential patient intake questionnaire and disclosures.
Background, Trauma & Lifestyle
Last section — Provide childhood, relationship, educational history and finalize your intake.
FAMILY BACKGROUND & CHILDHOOD
Birthplace
Where did you grow up?
Adopted? (At what age, details)
Early developmental problems?
NO
YES
Major childhood physical illness?
NO
YES
Childhood illness details
Siblings and ages
Are your parents divorced?
NO
YES
Custody arrangement details
PARENTAL RELATIONSHIPS
Mother's Occupation
Relationship with Mother
Father's Occupation
Relationship with Father
FAMILY PSYCHIATRIC & SUBSTANCE HISTORY
Is there any family psychiatric history?
NO
YES
Family psychiatric history details
Have any family members been medicated for mental health?
NO
YES
Family medications listed
Is there any family history of suicide?
NO
YES
Is there any family history of substance abuse?
NO
YES
Family substance history details
TRAUMA HISTORY & LOSSES
History of emotional, physical, sexual abuse or neglect?
NO
YES
If so, describe when, where, and by whom:
Have you lived through an experience you consider traumatic?
NO
YES
If so, what and when?
Has anyone close to you died recently or significantly impacted you?
NO
YES
Details of loss (who and when):
EDUCATION, EMPLOYMENT & MILITARY
Highest Education Completed
Student current school/grade (if applicable)
Have you attended college?
NO
YES
Where / Major
Occupational Status
Full-Time Student
Working
Not Working by Choice
Unemployed
Disabled
Retired
Occupation
Employer & Length of Employment
Have you served in the military?
NO
YES
Military details (branch, dates, discharge)
MARITAL, HOUSEHOLD & INSURANCE
Marital Status
Married
Single
Divorced
Widowed
Marriage/Relation Duration
Number of Marriages
Children (Names and Ages)
Other Household Members
Current Living Situation
INSURANCE INFORMATION
Insurance Provider / Type (e.g. Aetna)
Policy / Group #, Subscriber Name
LEGAL HISTORY & DEMOGRAPHICS
Have you ever been arrested?
NO
YES
If so, for what and when?
Spiritual life, religion or faith practices
HIPAA & Consent to Treat Acknowledgment
*
I read and acknowledge HIPAA Privacy Practices
By signing below, I acknowledge that I have received and read the Notice of Privacy Practices for Dual Recovery Solutions, LLC. (ViewPoint Dual Recovery Center). I understand my rights concerning Protected Health Information (PHI) and authorize treatment.
E-Signature of Patient or Authorized Representative
Signature Date
