INTAKE ASSESSMENT. 1. Print out the Intake Assessment or call ARISE Alcohol Recovery to have an assessment mailed to you.

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1 INTAKE ASSESSMENT Directions: Please complete all sections of the attached Intake Assessment form with as much accuracy as possible. You may have someone who knows you well assist you with completing the assessment; however, you are responsible for the accuracy of your answers. You may call ARISE if you have any questions about the admission process. In addition to completing this assessment, you will need to contact your physician(s) to have a copy of your medical and mental health records (if you have a psychiatrist) faxed to our office. These records must include your current laboratory reports, all current medications, all medical and mental health diagnoses and any medical or mental health treatments you are currently following. 1. Print out the Intake Assessment or call ARISE Alcohol Recovery to have an assessment mailed to you. 2. Complete the assessment (You may have someone assist you.) 3. Sign the Intake Assessment 4. Fax or mail your assessment to ARISE Alcohol Recovery 5. Have your physician(s) fax your medical and mental health records to us including: a) Current laboratory reports b) Current diagnosis (including medical and mental health) c) Current medications d) Current treatments 6. Call or ARISE to tell us you have sent us your assessment so that we can contact you in the event we do not receive it. ARISE ALCOHOL RECOVERY P.O. Box 886 Horse Shoe, NC : (828) Fax Number: (828) DrChapel@AriseAlcoholRecovery.com Web:

2 INTAKE ASSESSMENT Date: How did you hear about ARISE? Name: First Middle Initial Last Age Date of Birth Sex Highest level of education Marital Status: Single Married Divorced Widow/Widower Separated Never Married Do you live alone? If not, who do you live with? Who will be your support person throughout the six week program? (This person will stay with you during your initial detoxification period and attend the weekly family sessions for the entire six week program.) Name Relationship Telephone Name Relationship Telephone Name of employer (We will not contact you at your place of business nor will we contact your employer without your permission.) Current Legal Status including pending charges, parole status, probation, etc. Military History: Branch Date Type of Discharge Residence: House Condo Apartment Retirement Community Own Rent Primary Physician Psychiatrist ALCOHOL HISTORY Why are you seeking a program for alcohol recovery at this time?

3 What is it about this program that especially attracts you? PAGE 2 How old were you when you had your first drink? When did you start drinking regularly? How old were you when your drinking became a problem? What form of alcohol do you drink? How much and how often do you drink? Are you continuing to drink at this time? Please check all symptoms you have experienced while drinking or detoxing from alcohol. Black outs Seizures DT s Delusions Hallucinations Tremors Sweating Nausea Vomiting Cramping Agitation Insomnia OTHER SUBSTANCE HISTORY Are you currently taking any Benzodiazepines (Ativan, Valium, Xanax, Klonipin)? If so, please list names, amounts and times you take these. Are you currently taking any Opiates (Lorcet, Dilaudid, Morphine, OxyContin, Lortab, Hydrocodone, Methadone, Heroin, Demerol, Darvocet)? If so, please list names, amounts, by mouth or injection and times you take these?

4 Are you currently using Cocaine or Crack? If so, please list amounts, method and times you take these. PAGE 3 Are you currently taking any Amphetamines (Crystal meth, diet pills, special K, scoop, GHB, ICE, XTC, crank, Adderall, Ritalin, dextroamphetamine, speed)? If so, please list names, amounts and times you use these. Are you currently taking any Sedatives (SOMA, Ambien, barbiturates, other)? If so, please list names, amounts and times you take these. Are you currently taking any Hallucinogens (LSD, PCP, mushrooms, other)? If so, please list names, amounts and times you take these. Are you currently using Marijuana? If so, please list amounts and times you take this. Do you smoke or chew tobacco? If so, how much and how often? MENTAL HEALTH HISTORY Previous Psychiatric/Chemical Dependency Treatment Programs Date Location Inpatient Outpatient Do you currently have thoughts of suicide? Is so, please describe. Have you ever attempted suicide in the past? If so, what method did you attempt? Has anyone in your family ever committed suicide? If so, who? By what method?

5 Have you experienced any recent losses (death, move, relationship, health, etc.) Please describe. PAGE 4 Do you ever have violent thoughts toward people or property? Do you have a history of personal trauma or abuse, either emotional or physical? Yes Have you ever been diagnosed with Post Traumatic Stress Disorder? Yes Is your remote memory intact? Is your recent memory intact? MEDICAL HISTORY What is your height? What is your current weight? To what medications and foods are you allergic? What type of reactions do you have to each? List all your current medications, amount taken and how often. What is the name and telephone number of the pharmacy(s) where you purchase your medications? List all medical problems you are currently experiencing.

6 List other medical treatment and all surgeries. Date Location Inpatient Outpatient PAGE 5 Do you have an eating disorder (anorexia, bulimia, binge, purge)? Yes If yes, please explain. Have you ever been diagnosed with HIV/AIDS? Yes PARTICIPATATION IN THE ARISE PROGRAM Are you physically able to walk, bend and stretch? Yes If, please explain. Do you have any physical limitations that would prevent you from taking part in physical activities? If so, please explain. Do you currently have any gastro intestinal problems that would prevent you from taking food supplements and eating a typically healthy diet? If so, please explain. Do you have difficulty swallowing capsules? Yes Are you willing to follow a regular schedule for taking food supplements? Yes Can you be committed to following a healthy nutritional plan and sticking to it? Yes What concerns might you have about being able to follow the nutritional guidelines? HOLISTIC ORIENTATION

7 PAGE 6 Please number the words below in the order of how you would best describe your outlook on life. Conservative Traditional Open minded Flexible Holistic n Traditional Please check all the words below that you are comfortable with. Spirit God Source Universal Mind Universal Consciousness Other: ne of the above Have you ever attended AA? Yes If yes, how often did you attend? Regularly Sometimes Rarely Never What requests, questions or concerns do you have about the ARISE program? By signing this Intake Assessment I am agreeing to allow ARISE Alcohol Recovery L.L.C. to contact my pharmacy and/or physician(s) for verification of or additional information in order to process my request for admission into the ARISE Alcohol Recovery program. This information will be kept confidential and shared with no other persons for any reason. It may be necessary to contact my Support Person for additional information. By signing this Intake Assessment I agree to allow ARISE Alcohol Recovery L.L.C. to contact my Support Person. Support Person s Name My Signature Date Thank you for taking the time to complete this intake assessment. Our goal is to serve you in the best possible way. We look forward to receiving your medical records from your physician(s) so that we can make an informed decision regarding the appropriateness of our program for your needs and best interest. As soon as we receive those records we will contact you.