Personal Information
Full Name
Date of Birth
Gender
Female
Male
Other
Address
Phone Number
Email
Emergency Contact
Name
Relationship
Phone Number
Substance Use History
Primary Substance of Concern
Alcohol
Opioids
Stimulants
Cannabis
Nicotine
Other
How long have you been using this substance?
Frequency of Use
Date of Last Use
Treatment History
Have you been in treatment before?
Yes
No
If yes, please describe
Medical & Mental Health
Current Medical Conditions
Current Medications
History of Mental Health Concerns
Additional Information
What are your goals for treatment?
Anything else you'd like us to know?