Clone of New Patient Registration Form

How did you first hear about ASI?* This field is required.

Google Search

Google Maps

Attorney/Law Firm

Probation/Parole

Court/Court Staff

Treatment or Healthcare Provider

Family/Friend

Former ASI Client

Previous ASI Client

Social Media

Online Advertisement

Community/Professional Organization

Mailer

Other

If you selected mailer, please enter the access code from it* This field is required.If not, please enter NA (not applicable)

Patient Name* This field is required.

First Name

Middle Name

Last Name

Street Address* This field is required.

Address Line 1

City* This field is required.

State* This field is required.

Zip Code* This field is required.

County of Residence * This field is required.

Date of Birth* This field is required.

Social Security Number* This field is required.

Contact Number* This field is required.

Area Code

Phone Number

E-mail* This field is required.

Name of Insurance Company* This field is required.

Drivers License (Front)* This field is required.Or Other Form of Photo ID or Picture of Self

Drivers License (Back)* This field is required.Or Other Form of Photo ID

Sex* This field is required.

Male

Female

Refused

Military Status* This field is required.

Marital Status* This field is required.

Primary Source of Income* This field is required.

Sexual Orientation* This field is required.

Straight/Heterosexual

Gay/Lesbian

Bisexual

Other

Refused

Ethnicity* This field is required.

Puerto Rican

Mexican

Cuban

Other Hispanic or Latino

Not of Hispanic or Latino origin

Hispanic or Latino-Specific Origin no specified

Refused

Race* This field is required.

White

Black or African American

Asian

American Indian or Alaskan Native

Native Hawaiian or other Pacific Islander

Another Race

Refused

Referral Source* This field is required.

Refused

Individual/Self

Alcohol/Drug Use Care Provider

Other Health Care Provider

School (Educational)

Employer/Employee Assistance Program (EAP)

Other Community Referral

State/Federal Court

Other Court

Probation/Parole

Other Recognized Legal Entity

Diversionary Program

Prison

OWI/DUI

Other Criminal Justice Referral

Unknown Criminal Justice

Who referred you to our office?* This field is required.Please use n/a if not applicable

Who referred you to our office?* This field is required.

Please provide the name of the person or organization that referred you, if known: * This field is required.

Email of referral source for reporting purposesif known, see above

example@example.com

Phone number of referral source for reporting purposesif known, see above

Area Code

Phone Number

Arrests in the past 30 days* This field is required.

Yes

Refused

Type option 4

Arrests Related to Substance Use in Past 30 DaysRequired if above is yes (e.g. OWI/Possession/Public Intoxication, etc.)

YES

Refused

Arrests in the past 12 months* This field is required.

Yes

Refused

If yes, how many times?required if above response is yes

How many arrests PRIOR TO THE LAST 12 MONTHS* This field is required.

4 or more

Refused

Occupation * This field is required.

Do you feel safe at home?* This field is required.

Yes

Please ask me more about this

Are you currently pregnant?* This field is required.

YESNO

Health Insurance* This field is required.

Private Insurance

Blue Cross/Blue Shield

Medicare

Medicaid (Amerigroup/Total Care)

HMO

Other

None

Refused

Living Arrangement* This field is required.

Education Grade Level* This field is required.

Employment Status* This field is required.

Refused

Full Time

Part Time

Unemployed

Not In Labor Force- Homemaker

Not In Labor Force- Student

Not In Labor Force- Retired

Not In Labor Force- Disabled

Homeless

Not In Labor Force- Other

Education Grade Level (Highest Completed)* This field is required.

Refused

Less than one grade or no schooling

10-11

12 or GED

Vocational School

Self-contained special education

1st year college

2nd year college

3rd year college

4th year college

Some post-graduate study

Masters Degree Completed

Post-graduate study 19-25 years

What are we seeing you for?* This field is required.Please let us know why you are needing services?

If being seen for an OWI, have you completed the DOT mandated Drinking Drivers Education Class (OWI Weekend Program) ?* This field is required.

Yes

How would you rate your quality of life?* This field is required.

Very Dissatisfied

Dissatisfied