OPTUMUS WELLNESS LLC

OPTUMUS WELLNESS LLC

SAP Client Intake Form
Client Information
Full Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Emergency Contact name
Emergency Contact Number
Please enter a valid phone number.
Employment Information
Current Employer
Job Title/ Position
Supervisor/Manager Name
Supervisor/ Manager Number
Is your position classified as DOT safety-sensitive work?

YesNo
Date of Violation/Incident
Nature of Violation/Incident

Alcohol-relatedDrug-relatedOther
Are you currently on suspension or leave due to this violation?

YesNo
Choose the DOT Mode for employment

Federal Motor Carrier Safety Administration (FMCSA)Federal Railroad Administration (FRA)Federal Transit Administration (FTA)Federal Aviation Administration (FAA)The United States Coast Guard (USCG)Pipeline and Hazardous Materials Safety Administration (PHMSA)
Referral Information
Who referred you to this SAP evaluation?

EmployerSelfCourt/LegalOther
Have you previously undergone an SAP evaluation?

YesNo
If yes, please provide the SAP’s name and contact information:
Substance Use History
Have you ever used alcohol or drugs?

YesNo
If yes, please specify the substances used, frequency, and duration:
Have you previously received treatment for substance use?

YesNo
If yes, what type of treatment did you receive (e.g., inpatient, outpatient, counseling)?
Dates of treatment:
Outcome of treatment:
Appointment
Have you had a consultation with the SAP?

YesNo
Have you scheduled an SAP Evaluation appointment?

YesNo
Would you prefer to schedule a meeting in-person or via a video call?

In-PersonVideo Call
Medical and Behavioral Health Information
Do you have any current medical conditions?

YesNo
If yes, please describe the condition(s):
Are you currently taking any medications?

YesNo
If yes, please list your medications:
Do you have any mental health conditions (e.g., depression, anxiety)?

YesNo
If yes, please describe the condition(s):
Consent and Acknowledgment

By signing this form, I certify that the information provided is accurate and complete to the best of my knowledge. I understand that this information will be used for the purpose of my SAP evaluation and related recommendations. I consent to the release of information to my employer or other entities as required under DOT regulations and as outlined in Optumus Wellness' privacy practices.

I also acknowledge that I am responsible for completing the SAP's recommended actions before I may be considered eligible to return to safety-sensitive duties, in accordance with DOT guidelines.

Client Signature: __________________________________________
Date: __________________________________________________
Should be Empty:

OPTUMUS WELLNESS LLC

Client Information

Employment Information

Referral Information

Substance Use History

Appointment

Medical and Behavioral Health Information