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
-
Month
-
Day
Year
Date
Who is Completing the Referral
What Organization Are You With?
Email of Person Filling Out this Form
Who is reporting the information?
Patient
Family / Friend
Facility / Case Worker
Other
Patients Name
*
First Name
Last Name
Patient Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Sex
Female
Male
Date Of Birth
*
-
Month
-
Day
Year
Date
Age
Social Security Number
*
Emergency Contact
First Name
Last Name
Relationship to Patient
Emergency Contact Phone Number
Does the Patient Have Insurance?
Yes
No
Insurance Type
*
Policy Number
Group Number
Insurance #2 Type
Policy Number
Group Number
Patients Primary Care Provider
Select All Substances Currently Being Used:
Methamphetamine
Amphetamine
Heroin
Opiates
Fentanyl
Benzodiazepines
PCP
THC
Synthetic Marijuana
Tianeptine
Alcohol
Ketamine
GHB
Cocaine
Crack Cocaine
Barbiturate's
Other
Describe Usage: How Much, How Often, Last Use:
List All Current Withdrawal Symptoms:
Currently in Active Use
Clammy Skin
High Blood Pressure
Headache
Insomnia
Loss of Appetite
Nausea
Vomiting
Diarrhea
Dizziness
Irritability
Memory Loss
Ringing in the Ears
Aching
Paleness
Rapid Heart Rate
Heart Palpitations
Sweating
Tremors
Seizures
Anxiety
Fatigue
Other
List All Previous Withdrawal Symptoms:
Clammy Skin
High Blood Pressure
Headache
Insomnia
Loss of Appetite
Nausea
Vomiting
Diarrhea
Dizziness
Irritability
Memory Loss
Ringing in the Ears
Aching
Paleness
Rapid Heart Rate
Heart Palpitations
Sweating
Tremors
Seizures
Anxiety
Fatigue
Other
IV DRUG USE
No
Yes - Current
Yes - Past
If YES please describe:
Does the Patient Use Tabaco or Nicotine Products?
No
Smoke
Dip
Chew
Vape
Nicotine Replacement
Is The Patient On Any Prescribed Medications?
No
Yes
List Any Medications, Dosage, Route of Administration, and Dosage Frequency:
List any Drug Allergies:
Has the patient had surgery in the past 30 days?
Yes
No
If Yes - Describe:
Does the patient have any open or draining wounds?
Yes
No
If Yes - Describe:
Has the patient been admitted to any hospital in the last 30 days?
Yes
No
Patients Pharmacy:
Does the Patient Use a CPAP
No
Yes
Does the patient use any devices to aid in ambulation?
No
Cane
Walker
Wheelchair
Bed Bound
Treatment History
None
Residential
Detox
IOP
Outpatient
MAT
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?
Yes
No
Describe the reason for the referral or any other pertinent notes:
Discharge Plan:
If Available - Upload a photo of Insurance Card
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If Available - Upload a photo of Identification
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