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Potential Client's Name:
Interested in:
Residential
Detox (short-term)
Suboxone Therapy
Intensive Outpatient
I'm not sure
Financial information:
Self-Pay
Insurance
Operation UNITE
Medicare/Medicaid
Under-resourced
Experience treatment before?
yes
no
I'm not sure
Court-ordered?
yes
no
I'm not sure
Preferred substances:
Alcohol
Opiates (pain pills, etc.)
Methamphetamine
Benzos (Xanax, Valium, etc.)
Various substances
I'm not sure
Plans to arrive:
As soon as possible
I'm not sure
Additional comments:
This form was completed by:
Email address:
*
Phone number:
City, State:
Best person to contact:
Phone number:
Preferred contact method:
Phone
Email
Best time to call:
Morning
Afternoon
Evening
Security Code:
*
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