dummy formbalancehouse2022-06-02T04:03:38-06:00 Basic InformationApplication Date: MM slash DD slash YYYY Expected to Enroll Client Name Address City, State, Zip Client Cell PhoneClient Email Address AgeDOB MM slash DD slash YYYY SSN Highest level of education completed Military Service Yes No Is client currently enrolled in school? Yes No Is client currently employed? Yes No Current Occupation Legal problems? Past or present. Yes No Please 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 Name Phone Number Email Address Emergency Contact InformationFirst Name Last Name Relationship to Client Address City State Zip Code Cell Phone Email Address Father's InformationFirst Name Last Name Address City State Zip Code Cell Phone Email Address Mother's InformationFirst Name Last Name Address City State Zip Code Cell Phone Email 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? Yes No If so, what substances and how often?Tobacco Use: Yes No If so, what kind 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? Yes No If yes, when and what was the nature of the treatment?Therapist Name Phone Number Email Address Psychiatrist Name Phone Number Email Address Family history of mental or emotional illness/substance abuse?Has client been administered psychological testing in the past? Yes No If yes, when was it administered If yes, May we obtain a copy? Yes No What other interventions have you tried in the past?MedicalHas the client been vaccinated for COVID-19? Yes No If yes, please provide brand and dates of immunizations received:Brand Date MM slash DD slash YYYY Any 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? Yes No Please 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? Yes No If yes, please explain:Do any medications the client is taking cause sun sensitivity? Yes No If 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? Yes No If 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? Yes No Are there any physical reasons why client might have difficulty participating in our program? Yes No If yes, please explain:History of eating disorder/ disordered eating?Other InformationHow would you describe your present health? Excellent Good Fair Poor EmailThis field is for validation purposes and should be left unchanged. Δ
