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Rehab Application Form Template

Streamline Your Patient Application Process Efficiently

Handling rehab applications can be overwhelming, especially when dealing with multiple patient documents and tracking their progress. This rehab application form template is designed for rehab centers and clinics looking to simplify their onboarding process. With this template, you can effortlessly collect patient information, improve data accuracy, and ensure a faster review process, all while maintaining compliance with relevant regulations. Pre-built sections help you gather essential details quickly, so you can focus more on patient care. Discover how the live template can enhance your workflow today.

Use this Template (FREE) Live Preview
Full name
Date of birth
Email address
Phone number
Current address (street, city, state, ZIP)
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Emergency contact full name
Emergency contact phone
Emergency contact relationship
Parent/Guardian
Spouse/Partner
Sibling
Other family member
Friend
Case manager
Other
Please Specify:
Primary substance or issue you want help with
Alcohol
Opioids (e.g., heroin, painkillers)
Stimulants (e.g., cocaine, meth)
Cannabis
Sedatives/benzodiazepines
Hallucinogens
Other or not sure
How often do you currently use the primary substance?
Very rarely
Rarely
Sometimes
Often
Very often
Date of last use for the primary substance
Other substances used (select all that apply)
Alcohol
Opioids
Stimulants
Cannabis
Sedatives/benzodiazepines
Hallucinogens
Tobacco/Nicotine
Prefer not to say
Other
Please Specify:
Have you experienced withdrawal symptoms before?
Yes
No
Have you received treatment for substance use in the past?
Yes
No
Current medical conditions
Current medications
Mental health diagnoses (select all that apply)
None
Anxiety
Depression
PTSD
Bipolar disorder
Schizophrenia or psychotic disorder
Prefer not to say
Other
Please Specify:
Please list any allergies
Pregnancy status
Yes
No
Not applicable
Prefer not to say
Current legal status
None
Probation
Parole
Court-mandated treatment
Pending charges
Other
Please Specify:
Insurance provider name
Insurance member ID or policy number
Do you have health insurance?
Yes
No
Preferred program type
Inpatient/Residential
Outpatient
Either/Unsure
Preferred start date
Consent to be contacted about your application
Yes
No
Type your full legal name as signature
Date signed
I certify that the information provided is accurate
True
False
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paper art illustration depicting a rehab application form with design elements for FormCreatorAI article

When to use this form

Use this application to capture complete intake details before you book an evaluation. It fits outpatient PT/OT clinics, hospital programs, and home health teams. Ask applicants to share their condition, goals, and risks so you can triage faster, verify medical oversight, and place them on the right track. Pair it with the Symptom screening form to capture current issues, and use the Neurological exam form when you support stroke, TBI, or neuropathy cases. After review, hand off essentials to the Treatment plan development form so your team can set milestones and schedule sessions. The result: fewer phone calls, safer starts, and care that matches needs.

Must Ask Rehab Application Questions

  1. What condition or injury are you seeking rehabilitation for, and when did it begin?

    This sets the clinical context and helps you route the applicant to the right therapist or program. Onset and cause signal urgency and guide initial session length and testing.

  2. What symptoms do you have now, how often do they occur, and what triggers or relieves them?

    Patterns point to the right modality and pacing, and they help you prevent flare-ups. If headaches are a concern, invite the applicant to attach the Headache diary form for clearer tracking.

  3. What treatments or therapies have you tried, and what helped or made things worse?

    You avoid duplicating failed care and can build on what worked. These insights sharpen your plan and support realistic expectations.

  4. Do you have recent diagnoses, test results, or a clinician referral we should review?

    Verifying medical findings improves safety and readiness for therapy. It also streamlines communication with the referring provider.

  5. What medications, health conditions, or activity restrictions should we consider for safety?

    This protects the applicant from contraindications and guides exercise intensity. For hypertension or cardiac concerns, a recent Home blood pressure report form helps you adjust the program.

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