• Patient Intake - Opioid or Alcohol Abuse

    Patient Intake - Opioid or Alcohol Abuse

    APPLE RIDGE TREATMENT CENTER

  • Welcome to Evergreen Medicine. Our goal is to help you with your recovery from opioid and/or alcohol abuse.  We offer two programs in the office. One, an oral treatment called Suboxone film. Second, a once a month intramuscular injection called Vivitrol. Please fill out the following forms in their entirety. Once submitted, a cooridinater will call you to set up your appointment.

  • Date of Birth*
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  • Insurance Information

  • Do you have Medical Insurance*
  • Date of Birth of Subscriber*
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  • Relationship to the Subscriber*

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  • Do you have a secondary insurance?*

  • Please note, we will not put a requirement on these fields. However, if you do have a secondary plan and fail to input the information, you acknowledge you will be responsible for what you primary insurance does not pay. 

  • To help eliminate human error, please take a photo of the front and back of your insurance card.

  • Date of Birth of Subscriber
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  • Relationship to the Subscriber

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  • Today's Date*
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  • Patient Intake

    Evergreen Medicine
  • Past Substance Abuse, please check all that apply"*
  • Which Treatment Program are you looking for*
  • What form of Medication are you looking for*
  • Give approximate date of last use of illicit or narcotic drug:*
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  • Do you have a history of intravenous drug use?*
  • Did drug/alcohol use begin as recreational (boredom, fun, curiosity, peer pressure)*
  • Did drug/alcohol use begin due to treatment by a physician or surgery*
  • Does depression, anxiety or PTSD factor in to drug/alcohol use*
  • Which mental health problems do you currently suffer from*

  • Have you had previous addiction therapy, counseling or outpatient treatment?*
  • Do you have any pending or previous legal charges related to or caused by your addiction*
  • How many alcoholic beverages to you have in one week*

  • Do you feel alcohol relieves stress, depression or anxiety*
  • Have your family or friends discussed your alcohol consumption with you*
  • Are you Employed*
  • Do you have a family history of drug or alcohol abuse*
  • Should be Empty: