Intake Form
If you are seeking Suboxone services, please use the below link:
**(PLEASE SUBMIT YOUR RESPONSES IN ALL CAPITAL LETTERS)**
Gender *
Last Name *
Your answer
First Name *
Your answer
Date of birth *
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DD
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YYYY
Marital Status: *
Race *
Primary Phone Number *
Your answer
Secondary phone
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Email *
By supplying your email address, you are authorizing ICC to use your email address for communication including transmission of your personal and health related information.
Your answer
Address 1 *
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City / Town *
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Zipcode *
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Emergency contact name *
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Emergency contact phone *
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Emergency contact relationship
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Primary Care Doctor *
Your answer
Please select the service(s) you are seeking *
THIS FORM IS NOT FOR SUBOXONE PATIENTS. SEE BELOW LINK
Required
If you are seeking Suboxone services, please use the below link:
Diagnosis / Reason for visit *
Required
Please check any medication(s) that you are currently or have recently been prescribed
Are you currently being treated for by Mental Health or Substance abuse provider or program? *
If you answered yes to the previous question, please explain why you are seeking to transfer your services?
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Primary Insurance *
Primary Insurance ID # *
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Secondary Insurance
Your answer
Secondary Insurance ID #
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Are you available for last minute same day appointments?
Availability *
Earliest
9AM-12PM
12PM-4PM
Latest
Anytime
Monday
Tuesday
Wednesday
Thursday
Friday
Have you been seen at Island Counseling Center before? *
Required
Person completing this form: *
Referred by: *
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Additional Comments
Please indicate any additional information that would be helpful in scheduling an appointment
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For more information, please visit our website at www.iccworcester.com
Thank you for choosing Island Counseling Center
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