Opiate Screening & Intake Form
Opiate & Alcohol Screening & Intake Form
Alcohol Screening & Intake Form
Benzo Screening & Intake Form
For Office Use
For Office Use
For Office Use
PERSONAL INFORMATION
Patient Legal Name
First
Last
Referred by
Select
Friend
Therapist
Doctor
Ad
Internet
Other
If Other, please specify
Phone Number
Cell Phone
DOB
Select Date
Age
Sex
Choose one
Male
Female
Address
City
State
- States -
AL
AL
AK
AZ
AR
BC
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
- Province -
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip
Patient Email
Support Person Email
Are you covered by Medicare?
Yes
No
Aftercare the patient is willing to commit to after detoxification:
Counseling:
12 Step Meetings:
Primary Care Practitioner:
Counselor/ Psychiatrist:
Additonal Details:
Support Person Name:
Relationship:
Phone Number:
Support Email:
Is this person currently abusing any drugs/ alcohol?
Select
Yes
No
Has this person ever been prescribed opioids because of a workers’ compensation-related injury?
Select
Yes
No
If yes, are they still using opioids because of this injury?
Select
Yes
No
Medical Professionals currently being seen:
Diagnosis:
Alcohol Dependence:
Benzo Dependence:
Opiate Dependence:
Other:
Please specify:
C.C. Info:
Location:
Opiate Detoxification Programs:
Modified Detox:
# of days:
Suboxone Detox:
Accelerated Detox:
Rapid Benzo Detox:
Alcohol Detox:
Flumazenil Treatment:
Implant/Injection Only:
Naltrexone:
2 Month implant:
Injection:
Starting day:
Select Day...
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Starting date:
Select Date
Ending date:
Select Date
Number of days:
Last use will be:
Pharmacy #:
Physician's orders:
Medications called in:
Select
Yes
No
Total costs involved ($):
Deposit ($):
Discount ($):
Total to be collected ($):
Form Completed By:
Jennifer
Amy
Jen
Jacqueline
Other
SUBMIT FORM
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