AIMS Community Pre Appointment Form

  • Request an Appointment

  • Demographic Information

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Type of Service Requested:
  • Do you have a previously diagnosed substance use disorder?
  • Select SUD diagnosis:
  • Priority Population/Specialty Population (select any that apply)
  •  - -

  • Funding Information

  • Type of Funding
  • What County do you reside in?
  • Marital Status
  • Rows

  • Emergency Contact

  • Format: (000) 000-0000.

  • Pharmacy

  • Format: (000) 000-0000.

  • PCP

  • Do you have a PCP?
  • Format: (000) 000-0000.
  •  - -

  • Phyiscal Health

  • Are you currently pregnant?
  • History of Pregnancy?
  • Have you given birth in the last 60 days?
  •  - -
  • Do you have any current physical conditions, problems or concerns?
  • Does pain interfere with your daily activities?
  • Do you have any mental health conditions/co-occurring diagnosed disorders?
  • Do you currently have any allergies to any medications?

  • History

  • Rows
  • Have you ever received treatment for substance abuse in the past?
  • Have you experienced withdrawal symptoms in the past?
  • If yes, please mark all that you have experienced:
  • Rows

  • Tobacco/Smoking

  • Do you smoke or use tobacco?
  • Type of tobacco use:

  • Appointment Request

  •  - -

  • Please be aware that someone will call you regarding your appointment request within 24 business hours. 

    Please feel free to reach out directly at 412-440-7478 for additional information or assistance scheduling with AIMS.

  • Program Requirements:

  • I understand that I must submit a urine drug screen monthly while enrolled in AIMS program.*
  • I understand that I will meet with a member of my care management team twice per month as well as attend my regularly scheduled MAT appointment*
  • I understand I must submit a valid identification card and insurance card prior to my first appointment. This can be submitted through my patient portal.*

  • Health History

  • Rows
  • Rows
  • Rows
  • If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?

  • TB/HVC/HIV Risk Assessment

  • HCV Screening Questions

  • Were you born between the years of 1945 & 1965
  • Do you currently use IV drugs?
  • Have you previously used IV drugs?
  • Have you received a clotting factor produced before 1987?
  • Have you been on hemodialysis?

  • Human Immunodeficiency Virus Screening Questions

  • Do you currently use IV drugs?
  • Have you previously used IV drugs?
  • Do you engage in unprotected sexual activities?
  • Do you engage in sharing needles?

  • Tuberculosis Screening Tool

  • Have you traveled extensively (more than 4 weeks) outside the U.S in the last five years to high TB-incidence areas (Asia, Africa, South America, Central America)?
  • Are you an immigrant from a high TB-risk foreign country (includes countries in Asia, Africa, South America, and Central America)?
  • Have you resided in any of these facilities in the past year: jails, prisons, shelters, nursing homes and other long-term care facilities such as rehabilitation centers? (If an individual was a resident of any of these facilities and tested with the past three months, they do not need to be reassessed).
  • Have you had any close contact with someone diagnosed with TB?
  • Have you been homeless within the past year?
  • Have you ever injected drugs?
  • Do you or anyone in your household currently have the following symptoms, such as a sustained cough for two or more weeks, coughing up blood, fever/chills, loss of appetite, unexplained weight loss, fatigue, night sweats?
  • Do you currently have or anticipate having any condition that would decrease your immune system? (Examples: HIV infection, organ transplant recipient, treatment with TNF-alpha antagonist (e.g. infliximab, etanercept, others), steroids (equivalent dose of Prednisone 15mg/day for one month or longer) or any other immunosuppressive medications?

  • Recovery Capitol Assessment

  • 12 Step/Self-help group and spirituality assessment

  • Previous 12-Step or community support group attendance?
  • Current 12-Step or community support group attendance?
  • Do you have a sponsor?
  • Do you have a homegroup?
  • Belief in a higher power?
  • Currently practicing a religion?

  • Education, Employment, Military

  • Education History
  • History of learning difficulties
  • Barriers to Learning:
  • Are you currently employed?
  • Employment Status:
  • Are you satisfied with your job?

  • Military History

  • Military History
  •  - -

  • Transportation:

  • Do you have a valid driver's license?
  • Are you driving without a license?
  • Do you feel you would have reliable transportation to treatment?

  • Legal Status

  • Current Legal Status
  • Current legal status:
  • Involvement in Drug Court/DUI Court/JRS
  • Court Involvment
  • History of charges?

  • Current Living Situation

  • Do you feel your current living environment is conducive of recovery?
  • Have you moved in the past year?

  • Recreational & Self-Care

  • Do you feel you have been able to manage your money/finances?

  • BARC-10 Brief Assessment of Recovery Capital

  • Rows

  • 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.
  • Select Areas where you desire additional support
  • Should be Empty: