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Intake Form
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Email
*
Your email
First and Last Name
Your answer
Date of application
MM
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DD
/
YYYY
Referred By
Your answer
Currently Pregnant
Yes
No
Maybe
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Current Address
Your answer
Cell Phone Number
Your answer
Driver's License #
Your answer
Vehicle Year, Make, and Model
Your answer
License Plate Number
Your answer
Date of Birth
MM
/
DD
/
YYYY
Age
Your answer
SSN#
Your answer
Sobriety Date
MM
/
DD
/
YYYY
Reason for getting sober
Your answer
Sponsor
Your answer
Sponsor's Phone #
Your answer
Intravenous Drug User
Yes
No
Clear selection
Date Last Used
MM
/
DD
/
YYYY
Chemical Used
Your answer
Have you overdosed?
Yes
No
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Have you ever experienced a seizure?
Yes
No
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Have you ever attempted suicide?
Yes
No
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Please describe you past history with chemicals (experimental use)
Your answer
Please describe you past history with chemicals (regular use)
Your answer
Chemical(s) of choice
Your answer
Length of use
Your answer
Alcoholic or Addict
Your answer
Prior treatment, sober living, detox or 12 step program
Your answer
RX Medications and Reasons
Your answer
OTC (Over the counter) Medications and Reason
Your answer
Medical Conditions/Diagnosis
Your answer
Do you have a Primary Care Provider
Yes
No
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If yes, provider name
Your answer
Are you enrolled with OHP
Yes
No
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Have you been to the doctor in the last six months
Yes
No
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How would you rate your overall health upon intake (1 = very poor, 10 excellent)
Very poor
1
2
3
4
5
6
7
8
9
10
Excellent
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Please explain any health issues
Your answer
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