Fillable Admission Self-Assessment Form printable pdf download

Rosecrance is a behavioral health care organization that is bound by strict state and

federal privacy and confidentiality regulations. Please fax this form. Do not email.

Admission Self-Assessment

Name

Date of birth _____________

__________________________________________________

Employment/vocational

____ No ____ Yes: Employer: ____________________________________

Are you currently employed?

____ Full-time ____ Part-time _____ Daytime hours _____ Evening hours

If yes, please check all that apply:

Educational/learning

____ High school diploma ____ GED

____ Some college

What is your current level of education?

____ Associate’s

____ Bachelor’s ____ Master’s

____ Reading written material — books, papers, etc.

What is/are your favorite way(s) to learn?

____ Listening to lectures and/or audio tapes

____ Participation that helps me to experience new learning in some way

____ Visual presentation, such as pictures, movies, videos and DVDs

Military history

_______ No _______ Yes

Are you now, or have you ever been a member of the U.S. armed services?

_______ No _______ Yes

Did you engage in active combat situations?

Spirituality

_______ No _______ Yes

Do you have a religious preference?

_______ No _______ Yes

Do you believe in a Higher Power?

_______ No _______ Yes

Do you have any concerns about there being conflicts between treatment and your faith?

_______ No _______ Yes

Have you ever had any upsetting experiences related to religion?

_______ No _______ Yes

Are you interested in meeting privately with our chaplain during your time in treatment?

Personal history

In your lifetime, have you ever experienced or are you experiencing any of the following?

___ Grew up in a substance-abusing household

___ Grew up in household where there was physical abuse

___ Grew up in single-parent household with:

___ Raised by someone other than a parent

___ Have changed jobs frequently

____ mother ____ father

___ Been a victim of crime

___ Have personally experienced physical abuse

Describe: _____________________________

By whom? _____________________________

___ Had sexual relationship with IV drug user

Did you seek help? _____________________________

___ Past sexual experience that troubled me

___ Have personally experienced sexual abuse

___ Have often felt that I am different than others

By whom? _____________________________

___ Have struggled with managing anger

Did you seek help? _____________________________

___ Have struggled with impulsive behavior

___ Have experienced one or more traumatic events during life

___ Have struggled with low self-esteem

Describe: _____________________________

___ Others often turn to me for help or support

___ Have struggled with an eating disorder

___ Have felt discomfort in social settings

Describe: _____________________________

___ Have struggled with sexual confusion

___ Have engaged in behavior that involved injuring self

___ Have limited social or emotional support

Describe: _____________________________

___ Have a physical/functional disability

___ Past/current unstable living situation

___ Currently have pending legal issues

___ Have experienced significant loss (death, divorce, illness, etc.)

___ Have history of legal involvement

Describe: _____________________________

___ Have changed jobs frequently

___ Have struggled with depression or other mental health issues

___ Been a victim of crime

___ Substance use has interfered with marital/family relationships

Admission Self-Assessment Form

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