A Helping Hand- "Intake Form"
1.) Date of initial contact:
(ie. 08/17/09)
*
Check one:
New Client
Transfer
Re-admission
*
Name:
SS#
Street Address:
State:
Zip Code:
*
County:
*
Date of Birth:
(ie. 08/17/09)
*
Phone#:
Email:
Preferred method of contact:
Phone
Email
Age:
Gender:
Male
Female
*
How did you hear about us?
(Newspaper Ad, Client referral, etc...)
*
How long have you been dependent on opiates?
months
years
How much do you use per day?
mgs.
Route of use?
What other drugs do you use?
*
Are you currently taking any Benzo's, Valium, Xanax, Klonipins)?
Yes
No
Prior treatment attempts:
*
Have you been on a Methadone Maintenance program in the past?
Yes
No
*
Are you currently on a Methadone Maintenance program?
Yes
No
If yes, where?
Current Dose:
mg
Are you currently being treated for any medical conditions?
Yes
No
POC & Phone2:
Do you have transportation to the clinic?
Yes
No
*
Payment Method:
SelfPay |
MA | If MA: #
|
MCO
SelfPay w/Private Ins.
Name of Insurance Co.
Appointment Date:
Time:
Attended:
Yes
No
(For Office Use Only)
Appointment Date:
Time:
Attended:
Yes
No
(For Office Use Only)
st.net
A Helping Hand - 6401 Dogwood Rd - Suite 201 - Woodlawn, MD 21207 - Phone: (410) 653-0021 - Fax: (410) 653-0070
