FAMILY COUNSELING CENTER FOR RECOVERY

CLIENT REGISTRATION
Client Name:___________________________,___________________________________
Last
First
Middle Initial
Date:_______________________________Social Sec # ____________________________
Birthdate:____________________Race_____________Marital Status:_______________
Home Address:_____________________________________________________________
City:________________________State:____________Zip Code:_____________________
County________________________ Cell Phone __________________________________
Home Phone ___________________________ Work Phone _________________________
Emergency Contact ______________________________ Relationship________________
Emergency Contact Phone # __________________________________________________
Name & Address of Person Responsible for Payment:_____________________________
___________________________________________________________________________
EMPLOYMENT
Okay to call
Employer Name:______________________________________ work? _______________
Employer Address: ________________________________ Phone # _________________
Military Experience: ________________________________________________________
IF PATIENT IS A MINOR
Who has custody/guardianship: _______________________________________________
Parent’s marital status: ______________________________________________________
School:________________________________________ Grade: _____________________
PCP ___________________________________ Referral Source ____________________
INSURANCE
Primary Insurance: ______________________________Effective Date: ______________
Policy Number: __________________________________ Group # __________________
Relationship
Subscriber Name _____________________________ to Subscriber? ______________
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Current Medical Problems: __________________________________________________
__________________________________________________________________________
Current Medications: _______________________________________________________
__________________________________________________________________________
Pharmacy: ___________________________________Phone #: _____________________
Name of PCP: _____________________________________________________________
Known Allergies and Adverse Drug Reactions: __________________________________
__________________________________________________________________________
__________________________________________________________________________
Hospitalizations/Surgeries:___________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Previous Mental Health or Substance Abuse Treatment: _________________________
_________________________________________________________________________
Please circle item(s) below if the person seeking treatment has had any of the following in the
past six months:
Nervousness
Divorce
Inferior feelings
Depression
Suicidal thoughts
Difficulty concentrating
Homicidal thoughts
Extreme Fears
Separations
Loss of family member
Shyness
Drug Use
Anxiety attacks
Sexual Problems
Excessive alcohol use
Nightmares
Sleep Problems
Headaches
Problems w/children
Financial Problems
Overtiredness
Major illness
Unhappiness
Legal Problems
Eating problems
Difficulty w/friends
Memory difficulties
Educational problems
Lack of self control
Loneliness
Lack of motivation
Angry outbursts
Lack of energy
Health problems
Undue stress
Indecisiveness
Career problems
Work Problems
Frequent crying
SUBSTANCE USE HISTORY:
Presently Use

Previously Used

Substance
Alcohol
Marijuana
Cocaine
Valium, Xanax, Ativan
Pain Medicines (ie:Hydrocodone, Oxycontin, Percocet)
Heroin
Methadone
Suboxone/Subutex
Others: Please list

DRUG AND ALCOHOL SELF EVALUATION
Yes

No

___

___

1.

Have you ever had to see your doctor as a result of your drinking or drug use?

___

___

2.

Is your drinking or drug use affecting your home-life?

___

___

3.

___

___

4.

Have you ever been committed to a hospital or institution as a result of your
drug abuse or drinking?
Do you feel like you have more self-esteem when you are intoxicated?

___

___

5.

Is your drinking or drug abuse affecting your employment or business?

___

___

6.

Has your efficiency decreased since you began drinking or abusing drugs?

___

___

7.

___

___

8.

___

___

9.

Do you find you have a craving for a drink or your drug of choice at certain
definite times of the day?
Does your drinking or drug abuse make you careless of your family’s
well-being?
Have you lost time from work due to your drinking or drug abuse?

___

___

10.

Are you shy when you are not drunk or high?

___

___

11.

___

___

12.

Has your drinking or drug abuse affected your reputation with your family,
friends and business affairs?
Do you drink or use drugs to escape your troubles?

___

___

13.

Do you ever drink or use drugs alone?

___

___

14.

Have you ever felt bad about actions you took after drinking or using drugs?

___

___

15.

___

___

16.

Have you ever “blacked out” or had a loss of memory as a result of your
drinking or drug abuse?
Have you ever had problems sleeping as a result of your drinking or drug abuse?

___

___

17.

Do you ever feel like you need a drink or drug the next morning?

___

___

18.

___

___

19.

Do you find yourself associating with seedy people and hanging out in
dangerous or inferior environments since you began drinking or using drugs?
Is your drinking or drug use affecting your financial situation?

___

___

20.

Do you find you have less ambition when you are drinking or using drugs?

If you answer “yes” to 2 or more of the above questions, consider having a professional assessment.
Contact The Family Counseling Center for Recovery for an appointment today.

www.fccr-va.com