MN PREVENTION & RECOVERY ALLIANCE
Intake Information
Date of Self-Referral
*
-
Month
-
Day
Year
Date
How did you hear about us?
*
Are you already working with an MnPRA CPRS?
*
Yes
No
If yes, who?
Name
Client Information
Name
*
First Name
Last Name
Date of birth
*
/
Month
/
Day
Year
Date
Address
*
Address
Street Address Line 2
City, State & Zip
State / Province
Postal / Zip Code
Phone number
*
Okay to leave voicemail?
*
Yes
No
Social Security Number
*
Email Address
*
example@example.com
Chemical Use & Mental Health
Primary DOC, Additional DOCs
*
Frequency of Use / Use History
*
Last Date of Use / Withdrawal Potential
*
Have you had a comprehensive assessment for substance use in the past 12 months?
*
Yes
No
If so, where?
Date of comprehensive assessment
/
Month
/
Day
Year
Date
Insurance Information
Do you have insurance?
*
Yes
No
Provider name
Member ID
Group Name/ID
PMI #
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