New Patient Intake

Admission Criteria: Must have a substance use disorder, a mental health/behavioral health condition of psychoactive substance use and be 18 years or older. The substance use disorder must include an absence of active withdrawal symptoms. Must be willing and able to actively engage in and sustain treatment.

New Patient Intake Form

Contact us any time

Today's Date

Referral Source

Client Concern (Why are you seeking treatment?)

Services Requested

Recovery Coach

Recovery Support Navigator

Clinical

First Name

Last Name

Date of Birth

SSN:

Phone

Legal Issues?

Current Living Situation

Street Address

Street Address 2

City

State

Zip code

Race/Ethnicity

Primary Language

Marital Status

Number of Children

Gender Identity

Employer

Emergency Contact

Emergency Phone

Primary Care Physician

Date Last Seen

Current Medications

Insurance Provider

Insurance Number

Comments / Concerns

Free Text

Payee responsibility for no show/late cancellation policy. We work closely with your insurance company to ensure payment for our services. In the event your insurance company rejects the claims (deductible, ineligibility, etc.) you are responsible for the payment for services rendered. Please be advised that you must provide 24-hour notice for cancellation.

Failure to do so may result in your being charged for the missed appointment

I hereby give permission to furnish information, including a psychiatric diagnosis to my insurance company. In consideration of services rendered, or to be rendered, I hereby assign and transfer to: any benefits.