New Patient CRS Intake Documentation Logo
  • CRS Intake Pre-appointment

  • Demographics

  •  - -
  •  - -
  • Substance Abuse History

  •  
  • Tobacco / Smoking

  • Health History

  •  
  •  
  •  
  •  
  • Primary Care Physician

  •  - -
  • Pain Screening

  • PHQ-9, Trauma History Questionnaire

  •  
  • Trauma History Questionnaire

    The Following is a series of questions about serious or traumatic life events. Knowing about the occurrence of such events, and reactions to them will help us to develop programs for prevention, education, and other services. For each event, indicate whether it happened &, if it did, the number of times & your approximate age when it happened.
  •  
  • TB/HVC/HIV Rick Assessment

  • HCV Screening Questions

  • Human Immunodeficiency Virus Screening Questions

  • Tuberculosis Screening Tool

  • Recovery Capitol Assessment

  • 12 Step/Self-help group and spirituality assessment

  • Education, Employment, Military

  • Military History

  •  - -
  • Transportation:

  • Legal Status

  • Current Living Situation

  • Recreatational & Self-Care

  • BARC-10 Brief Assessment of Recovery Capital

  •  
  • Certified Recovery Services Referral

    Certified Recovery Services will provide support before, during and after treatment through lived experience of the recovery process. CRS services include Guidance in the recovery process, referral for needed support services, referral for self-help recovery supports, moral support, coaching and advocacy throughout the recovery process, guidance in building healthy social relationships and leisure, recreational activities.
  • Should be Empty: