Inpatient Detox Intake Form

Inpatient Detox Intake Form
Please complete the following information. Include medical records and copies of insurance cards if available. When you click "SUBMIT" the information will immediately be sent to one of our intake coordinators. They will reach out to the patient and to you to make sure the patient receives prompt attention. If at any point you have trouble filling out the form or if you prefer to do the referral by telephone, please call 888-988-9673.
Todays Date

MonthDayYear
Date
Who is Completing the Referral
Who is reporting the information?
Patients Name

First NameLast Name
Patient Phone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex
Date Of Birth

MonthDayYear
Date
Age
Social Security Number
Emergency Contact

First NameLast Name
Relationship to Patient
Emergency Contact Phone Number
Does the Patient Have Insurance?
Insurance Type
Policy Number
Group Number
Insurance #2 Type
Policy Number
Group Number
Patients Primary Care Provider
Select All Substances Currently Being Used:

Other
Describe Usage: How Much, How Often, Last Use:
List All Current Withdrawal Symptoms:

Other
List All Previous Withdrawal Symptoms:

Other
IV DRUG USE
If YES please describe:
Does the Patient Use Tabaco or Nicotine Products?
Is The Patient On Any Prescribed Medications?
List Any Medications, Dosage, Route of Administration, and Dosage Frequency:
List any Drug Allergies:
Is the Patient Pregnant?
Does the patient use any devices to aid in ambulation?
Does the patient have any significant medical needs or unstable medical conditions that we should be aware of prior to admission? Examples may include oxygen use, CPAP use, wound care, feeding tube, mobility assistance, uncontrolled blood pressure, unstable diabetes, seizures, dialysis, recent hospitalization, recent surgeries, or any other condition requiring ongoing medical monitoring or assistance. Please Describe:
Patients Pharmacy:
Treatment History
If the patient has a history of mental health disorders, please list:
Is the patient currently experiencing legal issues, is a sex offender, or has a history of violent behavior?
Describe the reason for the referral or any other pertinent notes:
Discharge Plan:
If Available - Upload a photo of Insurance Card

Cancelof
If Available - Upload a photo of Identification

Cancelof
Should be Empty: