Clone of AIMS Request an Appointment Form

Request an Appointment

Complete the form and a team member will call you within the next business day.
Demographic Information
Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
I'm referring an individual to the AIMS program, or I have been referred to the AIMS program by another provider:

YesNo
Referral Source
Referral Organization:
Name of Referral:

First NameLast Name
Referral Source Email
example@example.com
Referral Source Phone Number
Please enter a valid phone number.
Best way to reach you
Type of Service Requested:

Buprenorphine (Suboxone)Long-acting injectable Buprenorphine (Sublocade/Brixadi)Naltrexone (ReVia)Long-acting injectable Naltrexone (Vivitrol)CRS/Peer ServicesOther
Do you have a previously diagnosed substance use disorder?

YesNo
Select SUD diagnosis:

Opioid Use DisorderAlcohol Use DisorderOther Use Disorder
If other specify
Priority Population/Specialty Population (select any that apply)

Pregnant injection drug userPregnant substance userGiven birth within the past 28 days.VeteranInjection drug userOverdose survivor
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Gender
Race
Race Other:
Ethnicity
Ethnicity Other:
Last Four of SSN:
Smoking Status
Preferred Language
Funding Information
Type of Funding

MedicaidCommercialUninsuredOther
What County do you reside in?

AlleghenyWestmorelandOther
Marital Status

SingleMarried
How many individuals live in your house?
Total number of dependents

Calculation
Primary Insurance:
If available
Member ID:
If available
Secondary Insurance:
If Applicable
Member ID:
If available
Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship:
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Email
example@example.com
Pharmacy
Pharmacy Name
Pharmacy Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number
Please enter a valid phone number.
PCP
Primary Care Physician

First NameLast Name
PCP Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PCP Phone Number:
Please enter a valid phone number.
Date last seen

MonthDayYear
Date
Are you pregnant?

YesNoN/A
Do you have any current physical conditions, problems or concerns?

YesNo
If yes, please specify concerns
Do you have any mental health conditions/co-occurring diagnosed disorders?

YesNo
If yes, please specify diagnosis/concerns
Do you currently have any allergies to any medications?

YesNo
If yes, please specify allergies:
History

Past and Current Medication

	Name of Medication	Currently Prescribed? (Y/N)	Dosage/Frequency
1
2
3
4
5
6
7
8
9
10

Have you experienced withdrawal symptoms in the past?

YesNo
If yes, please mark all that you have experienced:

DiarrheaChills/SweatsTremors/ShakingIrritabilityNausea/VomitingAnxietyWeaknessHallucinationsTachycardiaIncreased Blood PressureOther
Have you ever received treatment for substance abuse in the past?

YesNo
If yes please describe:

Substances Used

	Age of First Use	Method of Use	How often	Date of last use	Avg. 24 hour use amount
Alcohol
Marijuana
Opiates
Heroin
Cocaine/Crack
Benzodiazepines
Amphetamines
Hallucinogens

Tobacco/Smoking
Do you smoke or use tobacco?

YesNo
For how many years have you used tobacco products?
Type of tobacco use:

Light Cigarette Smoker (1-9 per day)Moderate Cigarette Smoker (10-19 per day)Heavy Cigarette Smoker (20-39 per day)Very Heavy Cigarette Smoker (40+ per day)Chewing Tobacco / Smokeless TobaccoNicotine PouchesVape/E-CigaretteOther
On a Scale of 1 to 10, How Ready Are You to Quit Tobacco:

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Appointment Request
Date of Requested Appointment

MonthDayYear
Date
Hour MinutesAM/PM Option
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.
Is there anything else you'd like us to know?
Program Requirements:
I understand that I must submit a urine drug screen monthly while enrolled in AIMS program.*

YesNo
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*

YesNo
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.*

YesNo
By submitting this form via this web portal, you acknowledge and accept that risks of communicating your health information via this unencrypted email and electronic messaging and wish to continue despite those risks. By clicking "Yes, I want to submit this form" you agree to hold Jade Wellness Center harmless for unauthorized use, disclosure, or access of your protected health information sent via this electronic means.**

Yes

	Relationship	Name	Age	Monthly Gross Income
Self
Household member 1
Household member 2
Household member 3
Household member 4
Household member 5
Household member 6
Household member 7
Household member 8

	Now	Past	Never	Comments
Anemia
Arthritis
Bleeding Disorder
Blood Pressure
Bone/Joint Problem
Cancer
Diabetes
Epilepsy/Seizures
Eye Disease
Fibromyalgia
Muscle
Headaches
Head Injury
Brain Tumor
Hearing Problems
Heart/Cardiac Disease
Hepatitis
Kidney Disease
Liver Problems
Lung Disease
Oral/Dental Health
Stomach Issues
Seizures
Stroke
Thyroid
Infectious Diseases
Tuberculosis
AIDS/HIV
STI/STD
Learning Problems
Speech Problems
Anxiety
Bipolar
Depression
Eating Disorder
Hyperactivity/ADD
Schizophrenia
Sexual Problems
Sleep Disorder
Suicide Attempts
Suicide Thoughts

	Yes	Comments?
Anxiety
Bipolar
Depression
Eating Disorder
Hyperactivity/ADD
Obsessive Compulsive Disorder
PTSD/Trauma
Schizophrenia
Sleep Disorder
Suicide Attempts
Suicide Thoughts

	Operation / Hospitalization	Year	Comments
1.
2.
3.
4.
5.
6.
Additional

	0. Not at all	1. Several Days	2. More than half the days.	3. Nearly every day
1. Little interest or pleasure in doing things
2. Feeling down, depressed or hopeless
3. Trouble falling or staying asleep, sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself-or that you are a failure or have let yourself or your family down
7. Trouble concentrating on things, such as reading the newspaper or watching television
8. Moving or speaking so slowly that other people could have noticed. Or the opposite-being so fidgety or restless that you have been moving around a lot more than usual
9. Thoughts that you would be better off dead, or of hurting yourself

Request an Appointment

Demographic Information

Funding Information

Emergency Contact

Pharmacy

PCP

History

Tobacco/Smoking

Appointment Request

Program Requirements:

Health History

Pain Scale

TB/HVC/HIV Risk Assessment

HCV Screening Questions

Human Immunodeficiency Virus Screening Questions

Tuberculosis Screening Tool

Recovery Capitol Assessment

12 Step/Self-help group and spirituality assessment

Education, Employment, Military

Military History

Transportation:

Legal Status

Current Living Situation

Recreational & Self-Care

BARC-10 Brief Assessment of Recovery Capital

Certified Recovery Services Referral

	1. Strongly Disagree	2. Disagree	3. Somewhat Disagree	4. Somewhat Agree	5. Agree	6. Strongly Agree
There are more important things to me in life than using substances
In general I am happy with my life
I have enough energy to complete the tasks I set for myself
I am proud of the community I live in and feel a part of it
I get lots of support from my friends
I regard my life as challenging and fulfilling without the need for using drugs or alcohol
My living space has helped to drive my recovery journey
I take full responsibility for my actions
I am happy dealing with a range of professional people
I am making good progress on my recovery journey