Westview Self-Registration Intake Form

Name:_______________________________________________Date:_______________

Address:________________________________________________________________

State:_________ Zip:__________ Phone:(H)______________(W)______________

Age:______ Sex:______ Sequence #:______________(to be filled in by Westview staff)

Level of care requested: Detox_____ Residential Treatment_____
Intensive Outpatient_____ Outpatient_____(See Programs and Services for a description of services.)

Current Drug Use (Including Alcohol)
Drug__________;Route__________;Quantity__________;Frequency_________;
Last Used__________

Drug__________;Route__________;Quantity__________;Frequency_________;
Last Used__________


Suicidal? Yes_____ No_____ If yes, date last attempted:____________

Plan_______________________________;Describe_______________________________________


Major Stressors (Please check all that apply.)

_____Alcohol or drug use recurringly interfering with health, job or social functioning

_____Spouse/other complains of drinking

_____DWI record

_____Criminal record

_____Family or other violence

_____Job performance problem



Client Signature:__________________________Date:___________