Initial Consult for ADAP

Participant’s Info for Initial ADAP Consult

1. Name: Phone:

2. DOB: Sober Date: D/C Date:

3. Living Environment at Transition:

4. Address:

5. Email Address:

6. Please provide a copy of final Continuing Care Plan, Discharge Plan. If available, you can include it here:

7. Rehab History:

Type	Facility Name	Length of Stay	When	D/C Status
---ResidentialIOP
---ResidentialIOP
---ResidentialIOP
---ResidentialIOP
---ResidentialIOP
---ResidentialIOP

8. Drug of No Choice:

9. Legal Issues? YesNo

Explain:

10. Medical Issues? YesNo

Explain:

11. Medications:

Name of Medication	Dosage	Refills

12. Road Blocks to Recovery:

13. Struggles at Rehab:

14. Participant's Strengths:

15. Participant's Weaknesses:

16. Collateral Conacts:


Name: Relationship:
Address:
Email Address:
Phone Home: Cell:
Work: Fax:

Name: Relationship:
Address:
Email Address:
Phone Home: Cell:
Work: Fax:

Name: Relationship:
Address:
Email Address:
Phone Home: Cell:
Work: Fax:

Name: Relationship:
Address:
Email Address:
Phone Home: Cell:
Work: Fax:

Name: Relationship:
Address:
Email Address:
Phone Home: Cell:
Work: Fax:

Name: Relationship:
Address:
Email Address:
Phone Home: Cell:
Work: Fax:

Name: Relationship:
Address:
Email Address:
Phone Home: Cell:
Work: Fax:

Name: Relationship:
Address:
Email Address:
Phone Home: Cell:
Work: Fax:

Enter this code below:

Once your form is completed and you have clicked ‘Send’, click here to return to the Admissions Paperwork page.