Method of Payment

Employment Status

Covid Screening
In the past 24 hours have you experienced any of the following symptoms?

Have you been tested for COVID-19 within the last two weeks?

Treatment History
Have you ever been treated in our program? If yes, Include date and reason for discharge

Are you in treatment at another agency? If yes, what program and length of treatment

Prior Treatment History

Any chronic medical conditions? If yes, explain condition and medications

Have you ever been diagnosed with a mental health disorder? If yes, what was the diagnosis, by whom, any medications?

Are you or is there any chance you could be pregnant?
If yes, due date

Are you currently using substances? If so, select below

Please describe: Primary, secondary drug, frequency of use, route (IV, inhale, etc.) 
Have you had any overdoses in the last 30 days ? (FOR MAT APPOINTMENTS)

Referred by:

Other Input: