ADMISSION REFERRAL FORM

The following is a list of questions that we will be asking as part of your admission process. This information will help us to effectively link you to the services that will help you with your recovery process. Please answer as you feel comfortable and feel free to omit information you would rather discuss with us in person.

* REQUIRED FIELDS

Personal History

First Name: (*) Invalid Input Middle Name: Invalid Input Last Name: (*) Invalid Input Home Phone: Invalid Input Additional Phone: Invalid Input Address: Invalid Input INSURANCE INFORMATION Type of Insurance: (*) PrivateMedicareMedicaidNone Invalid Input Company Name: (*) Invalid Input EMERGENCY CONTACT Name: Invalid Input Relationship: Invalid Input Phone: Invalid Input Address: Invalid Input DESCRIPTION How did you here about us? Invalid Input SUBSTANCE ABUSE: ALCOHOL: Age of First Use (*) Invalid Input ALCOHOL: Last Use (*) Invalid Input OPIATES: Current Use (*) Invalid Input COCAINE: Age of First Use (*) Invalid Input COCAINE: Last Use (*) Invalid Input Benzodiazepines (Xanax, Ativan, Klonopin) : Current Use (*) Invalid Input Marijuana: Age of First Use (*) Invalid Input Marijuana: Last Use (*) Invalid Input PCP: Current Use (*) Invalid Input Other: Age of First Use (*) Invalid Input Other: Last Use (*) Invalid Input Have you been in substance abuse treatment before? Where & when? * (*) Invalid Input Have you received treatment for mental health emotional symptoms before? * (*) Invalid Input Do you have any physical health problems (diabetes, high blood pressure, Hepatitis, HIV)? * Invalid Input Do you have chronic pain? Have you been treated for pain issues? * Invalid Input Are you prescribed any medicines? Please list all: * Invalid Input Enter text:   Refresh Invalid Input

City: (*) Invalid Input State: (*) AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew New JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Invalid Input Zip: (*) Invalid Input S.S. #: Invalid Input D.O.B.: (*) Invalid Input Age: (*) Invalid Input Policy Number: Invalid Input City: Invalid Input State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew New JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Invalid Input Zip: Invalid Input What services are you requesting? (*) Invalid Input ALCOHOL: Current Use (*) Invalid Input OPIATES: Age of First Use (*) Invalid Input OPIATES: Last Use (*) Invalid Input COCAINE: Current Use (*) Invalid Input Benzodiazepines (Xanax, Ativan, Klonopin) : Age of First Use (*) Invalid Input Benzodiazepines (Xanax, Ativan, Klonopin) : Last Use (*) Invalid Input Marijuana: Current Use (*) Invalid Input PCP: Age of First Use (*) Invalid Input PCP: Last Use (*) Invalid Input Other: Current Use (*) Invalid Input Are you currently experiencing problems with depression, anxiety, eating disorders, or other mental health issues? Please describe. * (*) Invalid Input Have you ever been a victim of a trauma? Physical Abuse? Sexual Abuse? Emotional Abuse? Witness/Victim of street violence? Natural disaster? * (*) Invalid Input Have you had surgery? Please describe. * Invalid Input Are you allergic to any medicines? Any other allergies? * Invalid Input