Livengrin offers an Online Admissions form that prospective patients or referring sources can utilize to transmit information prior to admission.

Use of this form will assist in a more efficient and less time-consuming admission process.

Once the form has been submitted, a Livengrin admissions specialist will call within 24 hours to complete your application and arrange your appointment to arrive. Further information may be required from you at that time.

If you choose to provide information only upon arrival at Livengrin, this form can be a reference for the kinds of information to bring with you. However, it is important that you call our toll-free number (green box on the left of this page) ahead of time to make arrangements and confirm what information is necessary and helpful.

You may also download this as a PDF, and fax it to: Livengrin Admission Dept. 215-638-3628.

Demographic Information

*Patient's First Name:		*Last Name:
Nickname:		*Email:
Home Phone:		Work Phone:
Cell Phone:
*Address:		Address 2:
*City:		*State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
*Zip Code:
Social Security Number:		Sex:	M F
Marital Status:	Single Married Divorced Separated Widowed	Race:	African American Asian Hispanic White Other
*Date of Birth (xx/xx/xxxx):

Emergency and Referral Information

Emergency Contact:		Emergency Phone:
Relationship to Pt.:	parent spouse employer friend other
Name of Referral:		Referral Phone:
Address:		City:
State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	Zip:

*How did you hear about Livengrin?

Substance Abuse (please list in order of preferred use)

Substance 1

*Substance Type:	Alcohol Ativan Barbiturates Benzodiazepine Cocaine Crack Heroin Inhalants Marijuana / Hashish Methadone Methamphetamine Oxycontin Percocete Xanax Valium Other	*How often:	1-2 Times per week 1-3 Times per month 3-6 Times per week Daily Not in past month Once Unknown
*How long at current amount?		Age of first use:
*Last Use:	01 02 03 04 05 06 07 08 09 10 11 12   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970	Amount:
How Used:	ingested snorted smoked injected

Substance 2

Substance Type:	Alcohol Ativan Barbiturates Benzodiazepine Cocaine Crack Heroin Inhalants Marijuana / Hashish Methadone Methamphetamine Oxycontin Percocete Xanax Valium Other	How often:	1-2 Times per week 1-3 Times per month 3-6 Times per week Daily Not in past month Once Unknown
How long at current amount?		Age of first use:
Last Use:	01 02 03 04 05 06 07 08 09 10 11 12   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970	Amount:
How Used:	ingested snorted smoked injected

Substance 3

Substance Type:	Alcohol Ativan Barbiturates Benzodiazepine Cocaine Crack Heroin Inhalants Marijuana / Hashish Methadone Methamphetamine Oxycontin Percocete Xanax Valium Other	How often:	1-2 Times per week 1-3 Times per month 3-6 Times per week Daily Not in past month Once Unknown
How long at current amount?		Age of first use:
Last Use:	01 02 03 04 05 06 07 08 09 10 11 12   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970	Amount:
How Used:	ingested snorted smoked injected

Substance 4

Substance Type:	Alcohol Ativan Barbiturates Benzodiazepine Cocaine Crack Heroin Inhalants Marijuana / Hashish Methadone Methamphetamine Oxycontin Percocete Xanax Valium Other	How often:	1-2 Times per week 1-3 Times per month 3-6 Times per week Daily Not in past month Once Unknown
How long at current amount?		Age of first use:
Last Use:	01 02 03 04 05 06 07 08 09 10 11 12   01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970	Amount:
How Used:	ingested snorted smoked injected

 

Withdrawal Symptoms
Are you experiencing any of the following withdrawal symptoms? (check all that apply)

Presently:
Seizures	Hallucinations	Uncontrollable Shaking/ Tremors
Nausea/Vomiting	Severe Cramps	Other:

Ever:
Seizures	Hallucinations	Uncontrollable Shaking/ Tremors
Nausea/Vomiting	Severe Cramps	Other:

Medical Assesment

History		Prescribed Medication (Name, Dosage)	Do you take the medication as it is prescribed? (including forgetting to take medication)
Asthma	yes    no		yes   no
Seizures	yes    no		yes   no
Hypertension/ Heart Condition	yes    no		yes   no
Diabetes	yes    no		yes   no
TB	yes    no		yes   no
Chronic Pain	yes    no		yes   no
Other Physical	yes    no		yes   no
Allergies (food, drug, or environmental)	yes    no		yes   no
Mental Health Diagnosis	yes    no		yes   no
			yes   no
			yes   no
Special Needs (e.g. Physical Care, Mental Disability)	yes    no		yes   no

 

Primary Care Physician:		Phone:
Address:		City:
State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	Zip:

Social History

Current Legal Issues:			DUI?:   Yes No
Attorney Name:		Phone:
Address:		City:
State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	Zip:

Health Insurance Information

Patient's Employer:
Employer's Address:		City:
State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	Zip:
# Years/Months Employed:	years and months	Union Affiliation (if any):
*Insurance Plan Name:		Insurance Phone:
*ID #:		Group #:
Insurance Mailing Address:

Secondary Health Insurance Information

Subscriber's Name:		Employer's Name:
Employer's Address:		City:
State:	AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	Zip:
*Insurance Plan Name:		Insurance Phone #:
*ID #:		Group #:
Subscriber's SSN#:		Subscriber's DOB:

 

Livengrin Foundation for Addiction Recovery
800-245-4746

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