Client Registration Form For Substance Use And Mental Health Treatment Services

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Client Registration Form For Substance Use And Mental Health Treatment Services

Please fill out this form if you would like to register for substance use and/or mental health treatment services from SCAN.
Date of Registration:*

MonthDayYear
Date
Services you believe you may need (check all that apply):*

Substance Use Disorder TreatmentMental Health TreatmentRecovery Support ServicesMedical Assisted Therapy for AdultsNot sureOther (please specify):
Presenting Problem: Below please describe in as much detail the reason you want to register for substance use and/or mental health treatment services, including the problems or needs you have.