Telehealth Substance Abuse Service Enrollment Form
Personal Information
Full Name
Date of Birth
Gender
Female
Male
Non-binary
Other
Contact Details
Phone Number
Email Address
Home Address
Emergency Contact
Emergency Contact Name
Emergency Contact Phone
Relationship
Substance Use Information
Which substances do you seek help for?
Alcohol
Opioids
Cannabis
Stimulants
Prescription Drugs
Other
Brief History of Use
Current Health & Treatment Goals
Relevant Medical Conditions
What are your treatment goals?
Preferred Telehealth Schedule
Days and Times Available