Pre-Screening Form Name(Required) First Last Date of Birth(Required) MM slash DD slash YYYY Social Security NumberPhone(Required)Email(Required) Do you have insurance?(Required) Yes No What insurance do you have?(Required) Medicaid Commercial Insurance Insurance Number (11 digits)(Required)Name of Insurance Company(Required)Group Number(Required)Member ID(Required)Do you have a substance use disorder?(Required) Yes No Drug(s) of choice?Last Day of use? MM slash DD slash YYYY Are you experiencing withdrawal?(Required) Yes No Do you need detoxification?(Required) Yes No Are you enrolled in MAT?(Required) Yes No Are you in good standing?(Required) Yes No Please Select(Required) Methadone Suboxone Subutex Sublocade Vivitrol Dose (mg):(Required)Date of last dose taken? MM slash DD slash YYYY Do you have any medical complications that prevent you from using stairs? Example: walker, cane, etc(Required) Yes No If yes, list:(Required)Are you diagnosed with a mental health disorder?(Required) Yes No What is your diagnosis?(Required)Are you prescribed medication?(Required) Yes No What medications:(Required)Are you homicidal or suicidal?(Required) Yes No Do you have any abscesses or open wounds?(Required) Yes No Are you willing to engage in behavioral health treatment as recommended by Clinician?(Required) Yes No Are you being referred to us by another Program/Hospital?(Required) Yes No Name of Referent:(Required)Completed by: (Signature)(Required)Date(Required) MM slash DD slash YYYY
