Clone of New Patient Registration Form

1
Patient Name* This field is required.
First Name
Middle Name
Last Name
2
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
3
County of Residence * This field is required.
4
Date of Birth* This field is required.
Month
Day
Year
5
Social Security Number * This field is required.
6
Contact Number* This field is required.
Area Code
Phone Number
7
E-mail* This field is required.
8
Sex* This field is required.
Male
Female
Refused
9
Gender Identity* This field is required.
Man
Woman
Transgender Man (Female to Male)
Transgender Woman (Male to Female)
Genderqueer
Other Gender Identity
Refused
10
Sexual Orientation* This field is required.
Straight/Heterosexual
Gay/Lesbian
Bisexual
Other
Refused
11
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
12
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
13
Military Status* This field is required.
Please Select
Please Select
Veteran
Non Veteran
14
Marital Status* This field is required.
Please Select
Please Select
Divorced
Never Married
Now Married
Separated
Widowed
Refused
15
Primary Source of Income* This field is required.
Please Select
Please Select
Wages/Salary
Disability
Public Assistance
Retirement/Pension
None
Other
Refused
16
Are you currently pregnant?* This field is required.
Yes
No
N/A
17
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
18
Are you in care for a mental health disorder?* This field is required.
Yes
No
Refused
19
How many times have you been in treatment for substance use?
20
Are you currently in a recovery group such as AA or NA?* This field is required.
Yes
No
Refused
21
If yes, how many days have you attended in the past 30 days?
22
Please select all substances used* This field is required.
Alcohol
Aerosols
Alprazolam (Xanax)
Amobarbital, pentobarbital (Nembutal), and other barbituates
Amphetamine
Anestethics (chloroform, ether, nitroux oxide)
Bath salts, phenmetrazine, and other amines
Buprenorphine (Subutex, Suoxone)
Butorphanol (Stadol), morphine (MS Contin), opium and other narcotics
Choral hyrdrate and other non-barbituates sedatives/hypnotics
Chlordiazepoxide (Librium)
Cigarettes
Cigars or Pipes
Clonazepam (Klonopin, Rivotril)
Clorazepates (Tranxene)
Codeine
Combo/more than 1
Cocaine/Crack
Diazepam (Valium)
Diphenhydramine
Diphenylhydantoin/Phenytoin (Dilantin)
DMT, mescaline, peyote, psilocybin, STP and other hallucinogens
E-Cigarette/Vaping
Ethchlorvynol (Placidyl)
Flunitrazepam (Rohypnol)
Flurazepam (Dalmane)
Gasoline, glue, and other inappropriately inhaled products
Glutethimide (Doriden)
Halazepam, oxazepam (Serax), prazepam, temazepam (Restoril)
Heroin
Hydrocodone (Vicodin)
Hydromorphone (Dilaudid)
Ketamine (Special K)
Kratom
Lorazepam (Ativan)
LSD
Marijuana/Hashish, THC, and any other cannabis sativa preparation
MDMA, Ecstasy
Meperidine (Demerol)
Meprobamate (Miltown)
Methamphetamine/speed
Methaqualone (Quaalude)
Methylphenidate (Ritalin)
Nitrites
Non-prescription methadone
Other antihistamines, aspirin, Dextromethorphan (DXM) or other over the counter medications
Oxycodone (Oxycontin)
PCP
Pentazocine (Talwin)
Phenobarbital
Propoxyphene (Darvon)
Secobarbital/Amobarbital (Tuinal)
Smokeless Tobacco
Solvents (paint thinner and other solvents)
Synthetic Cannabinoid (Spice), Carisoprodol (Soma)
Tramadol (Ultram)
Triazolam (Halcion)
Unknown
23
What was the route of administration for the aforementioned substance(s)?* This field is required.Select all that apply
Inhalation
Injection
Oral
Other
Refused
24
Substance use in the past 30 days?* This field is required.
Please Select
Please Select
1-2 days in the past week
1-3 days in the past month
3-6 days in the past week
Daily
None in the past month
25
What was the age of first use?* This field is required.
26
Name of Insurance Company* This field is required.
Please Select
Please Select
Blue Cross Blue Shield
United Health Care/UHC/Optum
Cigna
Aetna
Iowa Medicaid- Wellpoint
Iowa Medicaid- Total Care
Other
27
Policy ID Number* This field is required.Please enter the full number
28
Group ID Number* This field is required.
29
Relationship to Policyholder* This field is required.
Please Select
Please Select
Self
Spouse
Dependent/Child
30
Policyholder Name* This field is required.
First Name
Last Name
31
Policyholder Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
32
Policyholder Date of Birth* This field is required.
Date
Year
Month
Day
33
Client Orientation Packet Please review the following information regarding our program policies, expectations, and your rights as a client. Thank you.
34
Your signature below indicates that you have read and understand the client orientation packet including informed consent, payment/fee for service agreements, rights and responsibilities, confidentiality statement and HIPPA NOTICES. I agree that if I am evaluated by a provisionally licensed/certified provider or any professional who is being supervised for certification/licensure, that this will be explained to me at the time of my evaluation and I have the right to consent or refuse to participate in any video or audio recording used for supervision purposes as explained to me by my evaluator. I certify that I will be participating in this telehealth session from within the state of Iowa and I agree and authorize that my credit card be charged the $125.00 fee for service in order for the service to be scheduled and completed with a qualified substance use disorder assessment provider. * This field is required.Please Sign Below
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