On Line Intake Form

Client Information:

First Name:   MI:   Last Name:   Last Name at Birth:

Home Address:  Street  City  State  Zip Code           Male   Female

Home Phone:     Work Phone:     Cell Phone: 

E-Mail:      Date of Birth (mm/dd/yyyy): SSN#::

Highest Grade Completed:   Race: Click To Choose White Black Alaskan Native American Indian Asian/Pacific Islander Puerto Rican Mexican Cuban Hispanic Other   Other Race Specify: :

Prior Treatment in the last Year?  Yes   No     Treatment at H.S.A. in the past?  Yes   No

Referral Source:    Referral Telephone: 

Insurance Information:

Do you have Health Insurance:  Yes   No               Name of Insured: 

Relationship to Insured:  Click To Choose Spouse Father Mother Child Other       Insured's Employer: 

Insured Date of Birth (mm/dd/yyyy):     Insured SSN#:    Group #:

Insurance Company:    Insurance Telephone:    ID#:

Drug & Alcohol Information:

Recent Drug or Alcohol Use.  List up to 3 substances you have been using in the order of severity:

Substance 1:  Click To Choose Alcohol Cocaine/Crack Marijuana Heroin Methadone Other Opiates PCP Hallucinogens Methamphetamine Amphetamines Other Stimulants Benzodiazepine Other Tranquilizers Barbituates Sedative Hypnotics Inhalants   Frequency: Daily 3-6 times per week 1-2 times per week 1-3 times per month Not in the past month Last Use (mm/dd/yyyy):

Substance 2:  Click To Choose Alcohol Cocaine/Crack Marijuana Heroin Methadone Other Opiates PCP Hallucinogens Methamphetamine Amphetamines Other Stimulants Benzodiazepine Other Tranquilizers Barbituates Sedative Hypnotics Inhalants   Frequency: Daily 3-6 times per week 1-2 times per week 1-3 times per month Not in the past month Last Use (mm/dd/yyyy):

Substance 3:  Click To Choose Alcohol Cocaine/Crack Marijuana Heroin Methadone Other Opiates PCP Hallucinogens Methamphetamine Amphetamines Other Stimulants Benzodiazepine Other Tranquilizers Barbituates Sedative Hypnotics Inhalants   Frequency: Daily 3-6 times per week 1-2 times per week 1-3 times per month Not in the past month Last Use (mm/dd/yyyy):

When was the last time you received treatment?  (mm/yyyy): Type of Last Treatment:  None Outpatient IOP Partial Halfway House Detox Inpatient Methadone

If you are currently having severe withdrawal symptoms please go to a hospital emergency room or call 911!

Mental Health Information:

If you are having thoughts of harming yourself or someone else please contract Crisis Intervention at 717-394-2631 or 911 emergency immediately!!!

Have you received Mental Health treatment in the past? Yes No Where (most recent): 

When?:    Type:  Choices Inpatient Outpatient Psychiatrist   Please list any mental health medications your are currently taking and the

 Daily Medication dosage:

Prenatal/perinatal Information:

Are you Pregnant?  Yes No   If yes estimated due date (mm/dd/yyyy): 

Are you receiving prenatal care?  Yes No   If yes Where?:

Have you given birth in the last 28 days?  Yes No

Employment/Legal/Funding Information:

Are you employed?  Yes No If yes Employer: 

Do you have Medical Assistance? Yes No   Are you a veteran?  Yes No

Do you have any other funding for treatment?  Specify: 

Are you involved with the criminal justice system?  Click To Choose No Probation Parole Incarcerated House Arrest Pending Charges

If you have pending charges please list them: 

Please list the best day & time for appointments:

You will be contacted by noon of the next business day by our administrative staff to schedule an intake appointment.

Please click on the submit button below to submit your intake form.