Pre-Intake form
Which of our services do you need assistance?
Please Select
Substance Abuse
Process Addictions
Behavioral Health
Mental Health
Family/significant Other Counseling
Please list the problem(s) which you are seeking help?
*
Name (as it appears on your insurance card)
*
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
*
Please Select
Male
Female
Non binary
Trans male to female
Trans female to male
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Social Security Number
*
Name of Insurance Company and Member ID (if applicable)
Type of Insurance
*
Please Select
None
Medicaid
Medicare
Commercial
Have you been treated in the past or currently for any mental health issues?
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Yes
No
If yes, for what diagnosis/diagnoses and what was the treatment time period?
Prescribed medications and dosages you are currently taking
*
Are you currently using/misusing/abusing drugs, alcohol, or other harmful substances?
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Yes
No
If yes, how are/ were the drugs administered?
*
IV
Nasal
Oral
Smoke
All of the above
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Are you currently in a treatment program?
*
Yes
No
How long have you been in your current treatment program? (if applicable)
Name of treatment program (if applicable)
Are you willing to submit to urine and/or mouth swab drug screens upon request? (answering no will result in admission being denied)
*
Yes
No
Any other relevant and/or vital information?
How did you learn about the RecoveryGlue.org Program?
*
Please Select
Internet search
Social media
Friend
Referring medical/treatment provider
Out reach from RecoveryGlue.org staff member
Other
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*** All new clients must be approved, in particular, potential clients currently or recently in a hospital, mental hospital, or involved with certain legal issues. Completion of this form does not imply or guarantee admittance into the RecoveryGlue.org program.
Please verify that you are human
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