Terre Haute IOP/PHP Intake Form

Use this form for Individuals requesting PHP or IOP services in Terre Haute Only

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Client Information

Today's Date

Full Name

Preferred Name

Social Security Number

Phone Number

Date of Birth

Sex at Birth

Male Female

Gender

Male

Female

Other

Comments

Client's Email address

Street Address

Apartment

City

State

Zip Code

Emergency Contact Name

Relationship to Client

Emergency Contact Phone Number

Emergency Contact Address

City

State

Zip

Insurance Information

Primary Insurance Carrier (write none if client does not have insurance)

Member or Policy Number (Write none if client does not have insurance)

Group Number

Subscriber Information

Subscriber is Client Subscriber is other than client

Subscriber Name if other than client

Subscriber Date of Birth (if other than client)

Secondary Insurance

Yes No

Secondary Insurance Carrier (write none if client does not have insurance)

Member or Policy Number (Write none if client does not have insurance)

Group Number

Subscriber Information Policy 2

Subscriber is Client Subscriber is other than client

Subscriber Name if other than client

Subscriber Date of Birth (if other than client)

Identification

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Primary Insurance Front

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Primary Insurance Back

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Please upload a file

Secondary Insurance Front

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Secondary Insurance Back

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Currently Under Medical Provider's Care (Physician, NP, PA) List out patient providers only

Yes No

List Provider's Name, Organization, City, State, Phone number if known

List all allergies and reactions

History of any of the following conditions?

Seizures

Yes

Date

Comments

Diabetes

Yes

Date

Comments

HIV/AIDS

Yes

Date

Comments

Yes

Date

Comments

Dialysis/Kidney Failure

Yes

Date

Comments

Hepatitis

Yes

Date

Comments

Medical Hospitalizations

Other Medical Issues we should know about?

Mental Health

Have you ever been diagnosed with a mental health condition ?

Yes No

Diagnosis and Hospitalization History

Employed

Yes No

Employer Name

Employer Phone Number

Housing Situation

Have you ever been accused or convicted of a crime?

Yes No

Please explain and give dates

List any Pending Charges and County and State and include warrants

Are you a registered sex offender

Yes No

Do you have a Probation/Parole officer or caseworker?

Yes No

PO/Caseworker’s Name:

Telephone Number

County, State

Services Requested

Terre Haute IOP with Men's Sober Living

Terre Haute IOP without Sober Living

Terre Haute PHP with Men's Sober Living

Terre Haute PHP without Sober Living

Client is being referred to Roadways to Recovery from another organization

Referrer Name

Referrer Organization

Referrer Contact Number

Referrer Contact Email

Contact Fax

Please upload the following documents

Medication List

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Medical Eval

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Therapy Notes

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Please upload a file

PROGRAM DISMISSAL AND REMOVAL FROM THE PROPERTY ACKNOWLEDGEMENT I understand that entrance into this program is voluntary and a privilege. This is not considered a residence but rather a program. In the event that any violation of the program rules or expectations could result in immediate dismissal from the program. I agree to adhere to the action of the program managers concerning dismissal. I agree that if asked to vacate the premises by management of Roadways to Recovery, I have a ONE (1) HOUR period to remove all personal items within the time allotted. If I refuse to vacate the premises or have not completely removed all personal items within the allotted time prescribed, I have been informed / agreed that you may be called to the premises to assist in my dismissal. It is also my full understanding that I will be allowed to re-enter this property only upon authorization from appointed staff. I understand that I have 5 days from the time of dismissal to remove my personal items from the property. If my items have not been removed, I understand that they will be donated at the staff's discretion. NOTICE: FAILURE TO COMPLY WITH THE TERMS OF THE PROGRAM DISMISSAL AND PERMANENT REMOVAL FROM THE PROPERTY COULD RESULT IN HARM OR DEATH TO YOURSELF OR OTHERS.Formatted text

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