Name: First, Middle Initial, Last
Age and Birthdate
Phone #:
Address,    City,     State,     Zip and County
Marital Status:
Group #:
Insurance ID #:
Have another Ins? If so, list:
Insurance Company
Outpatient Service you want:  
Trying to  schedule with a specific therapist?
If yes - who?
Appt Request:
After 5pm:
M, T, W, TH, F, ST
Who Referred you to HTC?
Reason for referral?
NOTIFICATION IN CASE OF EMERGENCY: Name            Address            phone #            Relationship:
Are you currently receving Mental Health services? If yes, where?
# Lifetime psychiatric
inpatient admits:   
Are you currently receiving Substance Abuse (SA) services? If yes, where?
Any Known Psychiatric Diagnosis :No  Yes   If yes, list
# of outpatient treatments:
Ever been diagnosed with ADD
or ADHD?If yes, which one?
# Previous SA  treatments:  
Currently drink alcohol/ use drugs? If yes list Name and frequency and route?
History of IV Drug Use:  No  or Yes  
Currently on any medications:  No   Yes  If yes:     
# of HTC Admits?:
Family currently receiving services here at HTC:    No    Yes  If yes, who:
For CHILD Candidate:      Parent/Guardian Name:             Address:              Telephone:   
For ADULT Candidate:  Legal Guardian?:    No  Yes  If so, Guardian Name:   Address: Telephone:   
Primary Language: English   Yes  No    If no, primary language?
Candidate have difficulty with    Hearing:           Reading:            Writing:          Yes or No?
# of arrest in last 5 years.  If yes, list
Does candidate need an interpreter?    
Any Past Military Services?
Today's Date:
Your email address
Please list any Comments you may have:
You will be contacted by telephone, within 24 hours with your scheduled date/time.
CONFIDENTIALITY:  State and Federal laws protect confidentiality for services received at HTC.
Pre-Assessment Intake Form
Horizon Treatment Center
24681 Northwestern Hwy Ste 306, Southfield, MI 48075-2302
248-423-1728 (Office) & 248-423-1734 (Fax)
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**Welcome to our New online Pre-Intake form - please complete in its entirety and you will be contacted within 24 hours with your scheduled appointment **
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