Rehabilitation Admission Form Template

This form supports the intake process for patients entering physical, occupational, or substance-use rehabilitation programs. It gathers medical history, previous hospitalizations, rehabilitation goals, type of rehab required, and referral information.

Key Features

• Rehabilitation type (physical, occupational, substance abuse, etc.)

• Referral source & reason for admission

• Past medical and psychiatric history

• Short-term and long-term rehabilitation goals

• Patient or guardian consent section

Who Should Use It

Rehab centers, physical therapy clinics, substance abuse recovery programs, and occupational therapy units.

• Version
• File Size 383.40 KB
• File Count 1