Please click here for the Irish Acres INITIAL INQUIRY/
PRE-REGISTRATION FORM

Phone: 203-785-1166
Fax: 203-773-1090
Please fill out ther online form below to receive more information regarding Irish Acres.

Fax: 203-773-1090

Date: // MM - DAY - YY
Name:
Gender: M F
Age:
D.O.B. // MM - DAY - YY
Address:
City:
State:
Zip:
Phone: --
Email:
Referred by:

Drug of Choice: Last Use://
Number of prior Detoxes (Sub. Abuse)

Number of prior In-Patients (Sub. Abuse)

Allergies (Food or Meds)
Current Prescription Meds
Marital Status: Single Married
Employment Status: Employed Un-Employed
1.) Where are you currently located? (i.e. - Home, detox)
2.) How are you planning to get here? (you can not drive yourself)
3.) Any legal issues pending?Yes No
What are they:
Past Current
4.) History of seizures?Yes No
What propted it?

5.) Do you have any physical limitations? (i.e. - stairs, long distances)
6.) If at detox we need History & Physical and PPD info faxed to
203-773-1090 Attn: Admissions

7.) Problem with an eating disorder? Yes No
If yes, when last active?

8.) History of attempted suicide or self mutilation? Yes No

9.) Ever been diagnosed with a psychiatric disorder? (depression, anxiety)
Yes No
Diagnosis: How long ago?
10.) Any inpatient for psych? Yes No
If yes, Where, When, Why??

11.) Are you currently seeing a psychiatrist or therapist? Yes No
Name:

12.) If so, are you willing to have him/her contact us? Yes No
Phone: --
13.) Any past or current medical problems or surgeries? Yes No
Treatment:

Method of Payment: