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Phone:INTAKE AP LOCATION FORM General Information:(PLEASE PRINT)Name: (Last) (First) (MI) Street: City: State: Zip: S. S. #: Driver's License/State ID: Birth Date: / / Ethnic Background: Marital Status:
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Start by opening the amethyst house intake screeningdoc in a word processing software.
02
Fill out your personal information such as name, date of birth, and contact information in the designated fields.
03
Answer the questions regarding your medical history, including any previous substance abuse treatment you may have received.
04
Provide details about your current substance use, including the specific substances you use and the frequency and amount of use.
05
Answer questions related to your mental health, including any history of mental illness or psychiatric treatment.
06
Indicate any medications you are currently taking and provide information about any known allergies.
07
If applicable, answer questions about your legal history, including any current or past legal issues related to substance abuse or criminal activity.
08
Finally, sign and date the screening document to indicate that the information provided is accurate and complete.
09
Submit the completed intake screeningdoc to the appropriate personnel at Amethyst House.

Who needs amethyst house intake screeningdoc?

01
Anyone who is seeking admission into Amethyst House, a substance abuse treatment facility, needs to fill out the amethyst house intake screeningdoc.
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Amethyst house intake screeningdoc is a document used for screening and assessing individuals who are seeking admission to the Amethyst house.
Individuals seeking admission to the Amethyst house are required to fill out and file the intake screeningdoc.
To fill out the amethyst house intake screeningdoc, individuals must provide accurate and detailed information about their personal background, substance abuse history, and treatment goals.
The purpose of the amethyst house intake screeningdoc is to gather necessary information to assess the individual's suitability for admission to the Amethyst house and to develop a personalized treatment plan.
The amethyst house intake screeningdoc may require information such as personal contact details, medical history, substance abuse history, current symptoms, and treatment history.
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