Tobacco Recovery Referral Form
Complete the form and a team member will call you within the next business day.
Demographic Information
Client Name
*
First Name
Last Name
Client Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Client Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Gender
Please Select
Male
Female
Non-Binary
Transgender
Other
Race
Please Select
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Other Race
Race Other:
Ethnicity
Please Select
Not Hispanic or Latino
Hispanic or Latino
Other
Ethnicity Other:
Last Four of SSN:
Preferred Language
Please Select
Declined to Answer
Chinese
English
French
German
Italian
Japanese
Mandar
Portuguese
Russian
Spanish
Tagalog
Other
Referral Source
Please Select
SCI Prison
Hospital
Inpatient Rehabilitation
PCP
Central Outreach
Prevention Point
Other
Referral Source Infromation
Referral Organization:
Name of Referral Source:
First Name
Last Name
Referral Source Email
example@example.com
Referral Source Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Best way to reach you
Please Select
Email
Phone
Other
Funding Information
Type of Funding
Medicaid
Commercial
Uninsured
Other
Primary Insurance:
If available
Member ID:
If available
Secondary Insurance:
If Applicable
Member ID:
If available
Emergency Contact
Emergency Contact Name
First Name
Last Name
Relationship:
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email
example@example.com
Nicotine/Tobacco Use
Does the client have a diagnosed substance use disorder including nicotine use disorder?
Yes
No
Select SUD diagnosis:
Nicotine Use Disorder
Opioid Use Disorder
Alcohol Use Disorder
Other Use Disorder
If other specify
Smoking Status
Please Select
Current every day smoker
Current some day smoker
Former Smoker
Never Smoked
Decline to Answer
Type of Tobacco Use
Light cigarette smoker (1-9/day)
Moderate cigarette smoker (10-19/day)
Heavy cigarette smoker (20-39/day)
Very heavy vigarette smoker (40+/day
Snuff user
User of moist powdered tobacco
Chews plug tobacco
Chews twist tobacco
Chews nicotine pouches
Vape/E-cigarrette
Specifiy amount and frequency of tobacco use habits
Appointment Request
Date of Requested Appointment
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Is there anything else you'd like us to know?
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Jade Wellness Center harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.*
*
Yes
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