Method of Payment
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?
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)