Intake Contact Form
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Email *
Full Name *
Address *
Phone Number *
Date of Birth *
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What is the reason for seeking services. Please include Substances used in the past and date of last use. *
Have you been in treatment before ?
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Are Pregnant or is there a possibility you could be Pregnant?
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Have you ever been under the care of a Psychiatrist or other Mental Health Provider? If so please list most recent appointment as well as condition being treated.
When was the last time you had a TB test? Have you ever tested positive for TB?
When was your last Physical?
Are you on any medications? If yes please list medication and reason for that medication.
Have you been vaccinated for COVID-19?
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Gender *
Race *
Are you a Veteran *
Do you live alone? *
Type of Residence *
Who Referred you to Confide?
Column 1
Parole
Probation
Court
Lawyer
STEP
Other Treatment Program
TASC
Treatment Court
None / Self referred
Other
Are you Employed
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Marital Status *
Highest level of education *
Do you have children *
If yes, How many? And do they reside with you?
Do you have Insurance? If no please provide weekly income to determine fee. If yes, list name of insurance company and ID number *
Do you agree to participate in telehealth sessions ( appointments by phone and/or video) *
Please list any information you feel is important for us to know prior to contacting you.
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