Call Us Toll Free : (877) 866-8661 Home About Us Reviews Resources Contact Articles   Yourself Friend or Family Patient or Employee               Preadmission Form Note: All fields are required! Name: Address: City: State/Zip: / Email: Age: DOB: Gender:  Male  Female Contact Numbers A convenient time to be contacted is:   Home: Work: Cell: Fax: PRESENTING PROBLEMS/SYMPTOMOLOGY: Please check as many as apply. Alcohol Depression Sexual Addiction Trauma Codependency Relationships Marijuana Prescription Drugs Heroin Methamphetamines Cocaine/Crack Ecstasy/MDMA Food Issues Gambling Religion Adrenaline/Risk Taking HOW LONG HAVE YOU BEEN USING YOUR DRUG OF CHOICE? 0-12 months 1-5 years 5-10 years 10+ years HAVE YOU EVER TRIED TO STOP USING?  Yes  No DID YOU EXPERIENCE ANY OF THE FOLLOWING SYMPTOMS? Tremors Headaches Swelling Vomiting Nausea Seizures Shakes Other:  HAVE YOU EVER BEEN TO DETOX?  Yes  No If "yes", when:  HAVE YOU HAD PRIOR TREATMENT?  Yes  No If "yes", where: when: Did you complete treatment?  Yes  No DO YOU DRINK OR USE DRUGS SOCIALLY?  Yes  No If "yes", are you facing any legal consequences as a result of your use?  Yes  No DO YOU USE NICOTINE IN ANY FORM?  Yes  No DO YOU HAVE A HISTORY OF UNDER EATING OR OVER EATING?  Yes  No If "yes", do you: Binge and/or Purge Compulsively over eat HAVE YOU ACTED OUT SEXUALLY IN ANY OF THE FOLLOWING WAYS: Extramarital Affairs Voyeurism Internet Chat Rooms Internet Pornography Online Fantasy Affairs Illegal Behavior e.g. prostitution, exposure ARE YOU CURRENTLY UNDER THE CARE OF: Psychiatrist Psychologist Counselor/Therapist IF GIVEN A DIAGNOSIS, WHAT IS IT? Name: Address: Phone: ARE YOU CURRENTLY ON ANY MEDICATION?  Yes  No Please list your medications and dosage and approximate date you began taking them: Medication Dosage Began PRESCRIBING PHYSICIAN'S NAME: HAVE YOU EVER THOUGHT PLANNED, OR ATTEMPTED SUICIDE? If so, when: Were you under the influence of your drug of choice at the time?  Yes  No Were you hospitalized after an attempt at suicide?  Yes  No HAVE YOU LOST YOUR JOB WHILE PRACTICING YOUR ADDICTION?  Yes  No ARE YOU ISOLATING FROM FAMILY AND FRIENDS?  Yes  No IS THERE A HISTORY OF ADDICTION IN YOUR FAMILY?  Yes  No CAN YOU WALK, DRESS, BATHE AND CARE FOR YOURSELF?  Yes  No HOW DID YOU HEAR ABOUT THE BRIDGE? Counselor/Therapist/Psychiatrist Bridge Alumnus Treatment Center Publication Church/Pastor Internet       Call Us Toll Free : (877) 866-8661