Outpatient MAT Intake Form

Outpatient Substance Abuse 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

MonthDayYear
Date
Who is Completing the Referral
Email of Person Filling Out this Form
Who is reporting the information?

PatientFamily / FriendFacility / Case WorkerOther
Patients Name*

First NameLast Name
Patient Phone Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex

FemaleMale
Date Of Birth*

MonthDayYear
Date
Age
Social Security Number*
Emergency Contact

First NameLast Name
Relationship to Patient
Emergency Contact Phone Number
Does the Patient Have Insurance?

YesNo
Insurance Type*
Policy Number
Group Number
Insurance #2 Type
Policy Number
Group Number
Patients Primary Care Provider
Is The Patient Interested In M.A.T Treatment
Select All Substances Currently Being Used:

MethamphetamineAmphetamineHeroinOpiatesFentanylBenzodiazepinesPCPTHCSynthetic MarijuanaTianeptineAlcoholKetamineGHBCocaineCrack CocaineBarbiturate'sOther
Describe Usage: How Much, How Often, Last Use:
List All Current Withdrawal Symptoms:

Currently in Active UseClammy SkinHigh Blood PressureHeadacheInsomniaLoss of AppetiteNauseaVomitingDiarrheaDizzinessIrritabilityMemory LossRinging in the EarsAchingPalenessRapid Heart RateHeart PalpitationsSweatingTremorsSeizuresAnxietyFatigueOther
List All Previous Withdrawal Symptoms:

Clammy SkinHigh Blood PressureHeadacheInsomniaLoss of AppetiteNauseaVomitingDiarrheaDizzinessIrritabilityMemory LossRinging in the EarsAchingPalenessRapid Heart RateHeart PalpitationsSweatingTremorsSeizuresAnxietyFatigueOther
IV DRUG USE

NoYes - CurrentYes - Past
If YES please describe:
Does the Patient Use Tabaco or Nicotine Products?

NoSmokeDipChewVapeNicotine Replacement
Is The Patient On Any Prescribed Medications?

NoYes
List Any Medications, Dosage, Route of Administration, and Dosage Frequency:
List any Drug Allergies:
Patients Pharmacy:
Treatment History

NoneResidentialDetoxIOPOutpatientMAT
If the patient has a history of mental health disorders, please list:
Describe the reason for the referral or any other pertinent notes:
If Available - Upload a photo of Insurance Card

Cancelof
If Available - Upload a photo of Identification

Cancelof
Should be Empty:

Outpatient Substance Abuse Intake Form