A staff member will contact you within 24 hours after you have completed the
pre-admission application to answer any questions and continue the process.
Completing the pre-admission form is not a guarantee or obligation for
treatment. Your information is confidential and will only be seen by the
River Source staff. Fields marked * are required.
I am looking for:
Relationship to patient:
Email address: *
Phone number:
Best # to be contacted at:
2nd choice:
Street Address:
City:
State:
Zip:
PATIENT INFORMATION
(If other than Self)
Patient name:
Age:
Date of Birth:
Gender:
Form of payment for treatment:
Marital status:
Number of Children:
Children ages:
Patient Street Address:
City:
State:
Zip:
Mental health status:
I'm concerned about my:
Yes
No
Alcohol
Consumption
Prescription drug use
Use of Other
Drugs
Are you a danger to yourself or others?
Have you attempted suicide in the last 12 months?
Have you considered suicide in the last 12 months?
Are there legal agencies involved (ex. courts, attorneys, probation officers):
Do you have allergies (List all allergies ex. food or medications):
Are you on any medications? (list all medications):
Types of alcohol and amount per day or week:
Types of drugs and amount per day or week:
Are you willing and able to get treatment at The River Source?:
Yes
No
Anticipated date of admission to River Source:
Anticipated length of stay:
Flight / Airline information (ex. airline, flight number, arrival date, arrival time etc.):
If we are picking you up at the airport please give us a physical description of yourself (height, weight, hair color, facial hair, eye color, what clothing you will be wearing that day etc.):
I am concerned about:
What are your goals with us? (ex. To live a life clean, sober and in recovery):
If yes please submit this form and contact us now at 1-888-687-7332.
Enter the shown code
If you or a loved one is looking for treatment for any type of substance abuse, please call NOW:
888-687-7332 . 480-827-0322 (your call is confidential)
