Get Impaired Nurse Treatment Program Intake Form

Filling out the Impaired Nurse Treatment Program Intake Form is an essential step for individuals seeking assistance through the program. This guide will provide clear and supportive instructions to help users navigate each section of the form online.

Follow the steps to accurately complete your intake form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the date you completed the form. Next, provide your name and date of birth.
3. Fill in your home and work phone numbers along with your mailing address. Select your sex from the options provided.
4. Input your registered nurse license number and the date it was issued.
5. In the emergency contact section, provide the name and relationship of the person to contact, along with their address and phone number.
6. Indicate whether you are licensed in any other state and provide the relevant state names and license numbers if applicable.
7. For the treatment readiness questions, describe what brought you to the program, your expectations, and any personal challenges regarding alcohol, drugs, or emotional issues.
8. Complete the personal status section by detailing your family background, current living situation, and marital status.
9. Provide information about your physical and medical history, including any medications you are taking and your current treatment from physicians.
10. Fill out the emotional and psychological history section, sharing details about any past or current counseling or therapy experiences.
11. Continue to the social history, legal history, and vocational history sections, providing accurate and thorough responses to each question.
12. In the chemical use history section, report on your substance use and any related concerns, including any relapses if applicable.
13. Finally, review all the information for accuracy. Once completed, save your changes and choose whether to download, print, or share the form.

Complete your intake form online today to take the first step towards support and recovery.