Hospital Referrals
If you are being referred to Ku Aloha Ola Mau by the hospital, please fill out the Hospital Referrals section only and sign your name at the bottom of the form and submit. No other information is needed. Ku Aloha will contact your social worker/staff worker.
Today’s Date:
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Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Print Full Legal Name
Applicants Name
Social/Staff Worker Name
Social/Staff Worker Number
Screening / Application
Print Full Legal Name
Today’s Date:
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Select Your Clinic:
Please Select
Hilo
Honolulu
Program Type
Please Select
Methadone
Suboxone
Who referred you to our program?
Date of Birth
Social Security #:
Physical Address:
Street, City, State, Zip Code
Are you a Hawaii resident?
Please Select
Yes
No
Marital Status
Please Select
Single
Married
Divorced
Telephone Number(s):
Please leave the best number so we can contact you to schedule an appointment
Home Phone #:
Cell #:
MEDICAL INFORMATION:
Medical Insurance
Please Select
Yes
No
N/A
Type:
Please Select
Medicare
Medicaid Quest
Commercial Insurance
N/A
Are you pregnant?
Please Select
Yes
No
N/A
If yes, how many weeks?
Have you ever been hospitalized?
If yes, how many times?
When was the last time?
What for?
List all prescribed medication
Are you allergic to any medications?
Please Select
Yes
No
N/A
If yes, please explain
Do you have any allergies to foods, insect bites, plants, animals, etc?
If yes, please explain
Substance Use
Please list all substances currently using
Substance Used
Date first used
How often?
Amount used
Date last used
Substance Used
Date first used
How often?
Amount used
Date last used
Substance Used
Date first used
How often?
Amount used
Date last used
Withdrawal symptoms
Signature
Required
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preview PDF
Submit
Should be Empty: