Alpha Recovery Screening Form

Alpha Recovery Online Screening Form

I am primarily interested in the: Atlanta Facility Brunswick Facility
Name:		Age:
DOB:		SSN:
Referred by:

Home Address:
City: State: Zip:
Home Phone:	Work Phone:
Employer (if unemployed, work skills):
Previous Employer:
Previous Employer:
Current Relationship Status:	SingleMarriedLive TogetherDivorcedWidow(er)
Partners Name:

Complete the following section only if you are currently incarcerated:

Name of Institution:

Address of Institution:

City: State: Zip:

EF#: Anticipated Release Date:

The section below concerns any previous treatment you have had:

Treatment Center:		Phone:
Counselor:		Doctor:
Admission Date:		Discharge Date:
Patient Number:		Aftercare:

Treatment Center:		Phone:
Counselor:		Doctor:
Admission Date:		Discharge Date:
Patient Number:		Aftercare:

Treatment Center:		Phone:
Counselor:		Doctor:
Admission Date:		Discharge Date:
Patient Number:		Aftercare:

This section outlines your prior drug history. Follow the key below to fill in the blanks beside each drug category. In the comment field, write about each drug you have used, including when and how you used it, and any triggers you know of that may cause you to relapse.

Last Date of Drug Use:

Drug of Choice:


Drugs Used:		Key:
	Recent	Means that you have used this drug within the past year.
	Past Only	Means that you used this drug, but it has been more than a year ago.
	Experimental Only	Means that you have only tried this drug a few times.
	Medical	Means that a doctor gave it to you and you took it as prescribed.
	Never	Means you never used this drug.

Depressants	Stimulants		Narcotics	Hallucinogens
Alcohol	Cocaine		Heroin	LSD
Benzodiazipine	Amphetamine		Opium	PCP
Barbiturates	Meth-amphetamine		Morphine*	Psilocybin
	Ice		Codeine**	Mescaline
Cannabis	Inhalants		Methadone	XTC/MDA
Marijuana		* Including morphine derivatives		GHB
Hash		** Including Codeine derivatives
List any other drugs you have done that are not listed above:
Other:			Other:
Other:			Other:

Comments about drug use:

Have you had previous involvement in:
12 Step Based Treatment Programs:		12 Step Meetings:		Do you have a sponsor:

This section concerns any previous psychiatric diagnoses you have been given. If you are on medication, give the name of the medication, daily dosage, doctor's name and directions for use.

Disorders other than addiction:

Current medications being used:

Have you ever attempted suicide? Yes No

If yes, when and how?

The following section concerns your driving privileges. You must provide a photocopy of a valid license and proof of insurance in order to bring a vehicle to Alpha facilities.

Transportation: Yes No	Year:	Make:	Model:
Insurance:	Suspended Revoked Valid	License #:	State:

This section outlines your previous criminal history.

Are you currently on Parole or Probation: Yes No

If yes, what jurisdiction:

If yes, who is your Parole/Probation Officer:

Phone:

Do you currently have charges pending: Yes No

If yes, what jurisdiction:

If yes, who is your Attorney:

Phone:

In this section, list all criminal issues, with dates, jurisdiction, and disposition. Also indicate whether or not the case is closed or current (active).
Active or Non-active	Date	Jurisdiction	List the Charges	Disposition

In the section below, we look at your financial obligation. At Alpha, we believe in being fully self supporting. Someone may help you for the first month. That give you two weeks to find a job, and two weeks to start drawing a paycheck. After the first month we expect you to be responsible for yourself.

How do you plan to pay your admission fee to Alpha?

If you are depending on a friend or relative to help with your fees, list their name, address and telephone number.

How do you plan to maintain your fees at Alpha?

This section authorizes the release of your information. If you are incarcerated or institutionalized, do not submit this form without a member of your institution present. The release of information is not valid unless it's submission is witnessed by an employee of the institution in which you are incarcerated.

By submitting this form, I authorize Alpha Recovery Centers to investigate any statements made on this application. I further authorize Alpha Recovery Centers to obtain information from any agency which could provide information to determine my eligibility for the program. I agree to hold harmless any agency which provides information which causes Alpha Recovery Centers to deny me admission to the program. I further authorize Alpha to contact employers and/or previous employers on my behalf. I further authorize Alpha Recovery Centers to release information to the Courts or to the State Board of Pardons & Paroles, concerning my eligibility to the program.

Please Enter Your Email Address Here Prior to Submission: