Book Appointment GeneralTell us about yourselfFirst NameMiddle NameLast NameWhen is your birthdate?What is your race/ethnicity?American Indian or Alaska NativeIndianAsianBlack Or African AmericanWhiteHispanicHawaiian Or Other Pacific IslanderWhat is your gender?MaleFemaleTransNon-BinaryWhat is your marital status?SingleMarriedDivorcedWidowedAre you a veteran?YesNoWhat is your email address?At what phone number can we best reach you at?Street AddressApartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweInsurance #1Client insurance provider:Client insurance Plan:Client insurance Group ID:Client insurance policy #:Client insurance other:Medical HistoryTell us about your medical history.When was your last relapse date?What is your substance(s) of choice?Prescription OpioidsMethAlcoholDepressantsStimulantsMarijuanaBenzodiazpinesCocaineHeroinAmphetaminesHallucinogensAdd multiple by clicking in the box and selecting different optionsHave you been clinically diagnosed with anything?Mental DisorderBipolar DisorderAnxiety DisorderSchizophreniaAnxietyPosttraumatic Stress Disorder (PTSD)Obsessive - compulsive disorderMajor depressive disorderPsychosisEating DisorderMood DisorderPsychological StressPersonality DisorderBehavioral DisorderDissociative Identity DisorderGeneralized Anxiety DisorderMixed Anxiety - Depressive DisorderBorderline Personality DisorderSelf-harmSocial Anxiety DisorderSchizoaffective DisorderAntisocial Personality DisorderMajor Depressive EpisodesParanoiaIntellectual DisabilityLearning DisabilitySomatic Symptom DisorderSeasonal Affective DisorderSpectrum DisorderPostpartum DepressionPsychomotor AgitationDelusional DisorderGender dysphoriaDevelopmental disabilityBipolar I disorderAdd multiple by clicking in the box and selecting different optionsaDo you have any health problems?Heart troubleHigh blood pressureArthritis or RheumatismCancerEmphysema or chronic bronchitisDiabetesStrokeBroken or fractured boneChronic nervous or emotional problemsParkinson's diseaseAdd multiple by clicking in the box and selecting different optionsaWhat kind of meetings do you attend?Refuge RecoverySmart RecoveryAANASLAAAdd multiple by clicking in the box and selecting different optionsWhat allergies do you have?Have you had any of the following tests?Medical Tests #1SelectMedical Tests #1Covid-19TuberculosisHepatitis CDate Performed On:NotesResultPositiveNegativeMedicationsList the medications you are currently prescribed.NameDosageQuantityCategoryAMMiddayEveningPMPRMQAMQDBIDFrequencyMdNotesPill CountDiscontinued atTreatment CentersTell us about any treatment centers you've previously been admitted into.Name Of CenterTreatment Center AddressTreatment Center CityTreatment Center StateTreatment Center ZipStartedEndedTypeIOPOPResidentialDetoxSober Living HistoryTell us about any sober livings you've previously been admitted into.NameDescriptionAddressCityState/ProvinceZIP / Postal CodeAdmittedDischargedEstimated length of stayReason for discharge:FinancialStaff RequestReplasedNormal TransitionEmploymentTell us about your employment status. If you're currently unemployed select "unemployed" under "type"Employer nameEmployment PositionEmployment IncomeNo Income$30000 - $50000>$50000Employment StartedEmployment EndedEmployment typeFull TimePart TimeUnemployedNot In Labor ForceHomemakerStudentRetiredDisabledInmateNot ApplicableVolunteerNot lookingInternshipEmployment notesLiving ArrangementTell us about your living arrangement prior to moving into this facilityArrangementShelterStreetInstitutionalOwnRentDormSober LivingTreatmentStartedEndedNotesCriminal HistoryDo you have any criminal history?YesNoIf so, what were you charged with?What is the status?Probation Officer InformationNamePhoneEmail AddressSend Message
