Pre-Intake Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Pre-Intake Form

Full Name *

DOB *

YYYY

SSN *

Address *

Phone number *

Insurance Carrier *

Have you ever been a client with us before? *

Yes

Primary Drug of Choice/Date of Last Use *

How soon are you wanting to commit to treatment? *

YYYY

Are you currently on MAT medication? *

Yes

Have you ever been diagnosed with a mental illness? *

Yes

Please list all mental illness diagnoses, if applicable.

Please list all medications you are currently taking, if applicable.

Are you currently on probation, parole, or involved with an active court case? *

Yes

If yes, please list the county/counties and the probation/parole officer(s).

Please list any current and/or pending charges, if applicable.

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report