Pecan Haven Addiction Recovery Center
Date of Birth
Please enter a valid phone number.
Street Address Line 2
State / Province
Postal / Zip Code
What is your motivation for treatment?
Have you been to any previous treatment programs including residential and/or detox? If so, where and when?
Do you have any legal issues or pending charges?
Are you currently on any prescribed medications? If so, list.
What drugs/alcohol have you been using? How much of each drug/alcohol? What is the date last used for each drug/alcohol? ANSWER ALL & INCLUDE ALL DRUGS/ALCOHOL
Do you need Detox?
Have you been taking Suboxone, Subutex, or Sublocade? If so, is it prescribed? How much and how often? Pecan Haven DOES NOT use any of these medications for Detox. You will not be allowed to take these medications while at Pecan Haven.
Do you have active medicaid?
Louisiana Healthcare Connections
Have you ever been diagnosed with any mental health conditions? Ex: Anxiety, Depression, Bipolar, Schizophrenia, Personality Disorder, PTSD etc.
Do you have any physical health conditions? If yes, explain. Ex: heart problems, hypertension, diabetes, asthma, kidney problems, Hepatitis, HIV/AIDS etc.
Have you been in a hospital recently? If yes, explain. Do you have any wounds that require bandages and/or dressing changes?
Do you require assistance with your activities of daily living? Ex: walking, eating, bathing? Do you use oxygen or require kidney dialysis?
Do you require a wheelchair or other assistive walking device?
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