Patient Name :

Name of Clinical Professional:

Discipline : Email :

Phone: Fax:

Address:

How Long Treating Patient?

Compliance with Treatment:

What behaviors are being exhibited that warrant inpatient treatment?

DIAGNOSES

Axis I:

Axis II:

Axis III:

Is Patient Medically Stable?

Axis IV:

Axis V:

MEDICATION (Please list all medications, dosages, dates prescribed, and reason for each medication)

We assume your patient will be coming off of all addictive substances. What are your thoughts about this?

PERTINENT INFORMATION History of Suicide Attempts / Suicidal Ideation:

History of Self-Mutilation:

History of Homicidal Ideation:

Psychosis:

HISTORY

Any safety concerns, given Sierra Tucson’s open campus?

How do you think your patient will interact in a process group?

Treatment goals / reasons for inpatient treatment:

Type of feedback requested:

Recommendations for aftercare:

I would like to receive a Sierra Tucson brochure

Self Evaluation

The willingness to become aware of your situation is the first step to diagnosis and treatment, which can bring healing, joy, and balance to your life! To begin select the type of evaluation:

- Select Evaluation - Alcoholism Anxiety Compulsive Gambling Depression Family Drinking Sexual Addiction

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