PATIENT RESPONSE

Full Name is required.
Please provide a valid date of birth.
Age is required.
Phone Number is required.
Please provide a valid email address.
Address is required.
Emergency Contact Name is required.
Emergency Contact number is required.
Emergency Contact Relationship is required.
Insurance Carrier is required.
Insurance Policy Number or ID is required.

PRESENTING CONCERNS

Please enter a valid why are you seeking care at this time?.
Please enter a valid what changes or improvements are you hoping for? .

SUBTANCE USE HISTORY

Substance Ever Used Currently Using Last Use Frequency Route (e.g., smoke, oral)
Alcohol
Cannabis
Methamphetamine
Fentanyl
Heroin
Prescription opioids
Benzodiazepines
Other
Age of first substance use is required.
Longest period of abstinence is required.
Most recent relapse (if applicable) is required.
Please select an option.
How many times is required.

PREVIOUS TREATMENT HISTORY

Please select an option.
Please Describe is required.
Please select at least one option.
Please Specify is required.
What has worked or not worked for you in the past? is required.

MENTAL HEALTH

Please select at least one option.
Please Specify is required.
Please select an option.
Please select an option.
Please select an option.
List medications is required.

PHYSICAL HEALTH

Please select at least one option.
Please Specify is required.
is required.
is required.
Please select an option.
explain is required.

SOCIAL & LEGAL HISTORY

Area Response
Current living situation
Do you live with someone who uses substances?
Children/dependents
Employment
Education level
Legal involvement
Spiritual or cultural beliefs important to your care?

STRENGTHS, READINESS & PREFERENCES

Please select at least one option.
Other Strengths is required.
Please select at least one option.
Other Services is required.
Goal 1 is required.
Goal 2 is required.
Goal 3 is required.

WELLNESS DOMAINS

Wellness Area Rating (1-5) Notes / Goals
Please rate the following areas of your life on a scale of 1 to 5:
(1 = Needs a lot of support, 5 = Feeling strong)
Physical Health
Mental/Emotional Health
Substance Use Recovery
Sleep Quality
Nutrition/Eating Habits
Relationships/Social Support
Work/Education/Purpose
Spirituality/Inner Peace
Housing Stability/Safety
Financial Stability

EMERGENCY & SAFETY

Please select an option.
thoughts explanation is required.
Please select an option.
Please select an option.

CONSENT AND ACKNOWLEDGEMENT

Select a country first.