Client Applicationbalancehouse2020-01-23T06:26:33-07:00 Client Application Step 1 of 4 25% Basic InformationApplication Date: Date Format: MM slash DD slash YYYY Expected to EnrollClient NameAddressCity, State, ZipClient Cell PhoneClient Email Address AgeDOB Date Format: MM slash DD slash YYYY SSNHighest level of education completedMilitary ServiceYesNoIs client currently enrolled in school?YesNoIs client currently employed?YesNoCurrent OccupationLegal problems? Past or present.YesNoPlease explainIs there anything else that we should know that is not listed above?Referral InformationHow did you hear about the Balance House Programs?Educational/Therapeutic ConsultantInterventionistTherapistPrevious FamilyPsychiatristAttorneyProgramHospitalGoogle SearchReferral Source NamePhone NumberEmail AddressEmergency Contact InformationFirst NameLast NameRelationship to ClientAddressCityStateZip CodeCell PhoneEmail Address Father's InformationFirst NameLast NameAddressCityStateZip CodeCell PhoneEmail Address Mother's InformationFirst NameLast NameAddressCityStateZip CodeCell PhoneEmail Address Marital Status of ParentsAre Parents Divorced/SeparatedNoYesIf yes, when?Are there any special circumstances?Has divorce/separation been an issue for your son?TreatmentWhat specific events precipitated enrollment into EVNSQ and the Balance House Program?What are your specific objectives for you and your son while he is enrolled in the EVNSQ and the Balance House Program? (I.e. Lifeskills, therapy, sobriety, self-esteem, identity, independence.)Does client use alcohol and/or drugs on a daily basis?YesNoIf so, what substances and how often?History of seizures or blackoutsHas your son been in treatment before? If yes, please indicate places and datesPlease indicate areas in which you have seen your son struggleDepressionPTSDAnxietyBi PolarIdentityIndependenceAttachment IssuesADD/ADHDExecutive FunctioningGrief and LossEntitlementOppositional DefianceHistory of trauma/abuse/being bullied?Describe any depressive features, mood swings, or isolationHistory of physical aggression?Has client ever been under the care of a psychiatrist or therapist?YesNoIf yes, when and what was the nature of the treatment?Therapist NamePhone NumberEmail AddressPsychiatrist NamePhone NumberEmail AddressFamily history of mental or emotional illness/substance abuse?Has client been administered psychological testing in the past?YesNoIf yes, when was it administeredIf yes, May we obtain a copy?YesNoWhat other interventions have you tried in the past?MedicalAny current or past history of chronic pain?Are there any current/past medical issues that need to be assessed by our medical staff?Have you ever had a head injury (TBI)?Are there any known allergies? Medical InformationIs the client currently taking any medications?YesNoPlease note that you will need to supply a copy of the doctor’s prescription or original bottle to the program for any continuing medicationsName of Medication(s) EXACTLY as indicated on the package/prescription (am/pm dosage)Has client been taking medication(s) long enough to be stabilized?Has client ever been on Medication Assisted Therapy (MAT)? (Subutex, Suboxone, MethadonePlease list any previous medications prescribed for emotional, behavioral, or substance abuse issues, attention deficit and the approximate date and the positive or negative result of each:Please indicate history in regards to taking medicationsTakes regularly without issueResistantForgets to take on occasionAre there any potential risks such as dehydration or irregular food intake associated with medications the client is taking?YesNoIf yes, please explain:Do any medications the client is taking cause sun sensitivity?YesNoIf yes, list medications:Has the client recently been taken OFF any medications? If so, please list medications and circumstances:Is the client allergic to any medications?YesNoIf yes, please list the medications and the allergic reactions:For drugs that require a stabilization period we will need confirmation by the client’s prescribing physicianIs client sexually active?YesNoAre there any physical reasons why client might have difficulty participating in our program?YesNoIf yes, please explain:History of eating disorder/ disordered eating? Insurance InformationInsuranceInsured First NameMiddle NameLast NameSocial Security Number of InsuredDate of Birth of Insured Date Format: MM slash DD slash YYYY Employer of InsuredEmployer’s Street AddressEmployers CityStateZip CodeRelationship of Insured to client:Insurance CompanyInsurance Company AddressCityStateZip CodeInsurance company phone numberGroup NumberPolicy NumberType of InsurancePolicy coverage/restrictions/limitations Other InformationHow would you describe your present health?ExcellentGoodFairPoorPhoneThis field is for validation purposes and should be left unchanged. For Help, Call Balance House Today Our team of admissions counselors are standing by. Call (801) 851-5260 to learn more about how addiction treatment can transform your life.