Full Name
Date of birth
City
State
What is your gender?
Please tell us why you're seeking treatment today?
Privacy Policy
Do you have secondary insurance?
Yes
No
If yes, name of insurance company
Have you been convicted of a physical crime?
Yes
No
If yes please explain
Have you ever been convicted of a sexual crime?
Yes
No
If yes, please explain
Substance Use
Alcohol
Marijuana
Cocaine
Meth
Heroin
Fentanyl
Prescription Drugs
Opoids
Benzo
Adderall/Stimulants
Hallucinogens
Kratom
Inhalants
Please list other substance use.
How much were you typically using?
When was your most recent use?
Are you currently experiencing withdrawal symptoms?
Are you currently experiencing any of the following
Seizures
Hallucinations
Confusion
Loss of consciousness
None of the above
Do you have any medical conditions that we should be aware of?
If you have a seizure disorder, when was your most recent seizure?
Have you ever been diagnosed or experienced with any of the following?
Anxiety
Depression
Bi-Polar Disorder
PTSD/Trauma
ADHD
Panic Attacks
Other
Please list any current medications.
Do you have any medication allergies?
Yes
No
Not sure
If yes what medications are you allergic to?
Have you received mental health or substance abuse treatment in the past?
Yes
No
