Contact Us

What other questions can we answer for you? What services are you looking for? What else can we do to help?

303 21st Street
Newport, MN, 55055
United States

(651)560-0050

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Adult Intake Form

This may take 10-15 minutes to complete and cannot be saved while in process, so make sure you have enough time before beginning.

Name *
Name
Date of Birth *
Date of Birth
Email preferences *
Check all that apply
Mobile *
Mobile
This number is where you will receive reminder calls of your appointments unless you opt out.
Home
Home
We encourage having two numbers on file in case of emergency office cancellations
Work
Work
Significant Other's Name (If applicable)
Significant Other's Name (If applicable)
Emergency Contact *
Emergency Contact
Emergency Contact phone *
Emergency Contact phone
Background Information
What areas of your life do you feel are impacted by this problem/issue?
Select all that apply
Abuse
Sexual Abuse
Physical Abuse
Self Injury
Suicide Attempt
Violent behaviors
Substance Use
Do you drink alcoholic beverages?
Do you sometimes drink more than you had planned?
Have family or friends ever expressed concern about your drinking?
Have you ever been arrested for alcohol related charges: DWI, public intoxication, etc?
Have you ever been treated for drinking or gone to AA?
Have you ever had episodes where you were unable to remember periods when you were drinking?
What do you drink?
(Check all that apply)
How often do you drink?
What has been your experience with Tranquilizers? (Valium, Librium, Azene, Milltown, Equanil, Xanex, Centrax)
What has been your experience with Pain Pills/Narcotics? (Darvon, Codeine, Percodan, Demerol, Dilaudid, Heroin, Talwin)
What has been your experience with Stimulants? (Amphetamines, Speed, Dexedrine, Ritalin, White Crosses, Zip, Cocaine & Derivatives, Crack, Crank, Methamphetamine)
What has been your experience with Sleeping Pills/Soporific? (Derided, Placidly, Dalmane, Seconal, Tuinal, Nembutal, Amytal, Phenobarbital, Noctec, Somnos)
What has been your experience with Hallucinogens? (Marijuana, Hashish THC, LSD, Mescaline, Psilocybin, MDA, PCP, Angel Dust, Mushrooms)
What has been your experience with Volatiles? (Aerosols, Paint Thinner, Glue, Lacquer, Amyl Or Butyl, White “Poppers”, Gasoline)
What has been your experience with other illicit drugs?
Have family or friends ever expressed concern over your use of drugs?
Have you ever been arrested for any offense involving drugs?
Have you ever been treated for chemical dependency?
Have you ever overdosed on drugs?
Do you have a family history of chemical dependency/alcoholism?
Health
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