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Full Name
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Male/Female
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Street Address
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City
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State
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Zip
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Home Phone
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Cell Phone
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Work Phone
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Date of Birth (MUST BE 18 YRS OR OLDER)
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Referred By
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Email Address
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Family Physician
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Name of Spouse & Contact Number
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Do you have Insurance?
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Insurance Company
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Insurance ID#
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Insurance Group
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Customer Service Phone#
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Insurance Policy Holder full Name
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Insurance Policy Holder Relationship to you
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Insurance Policy Holder Address
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Insurance Policy Holder Phone #
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Insurance Policy Holder Occupation
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Insurance Policy Holder Employer
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Insurance Policy Holder SSN#
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Insurance Policy Holder Date of Birth
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Duration of Substance Abuse?
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How Often/How Much Using?
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What are you currently using at this time?
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Alcohol?
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Methamphetamine?
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Heroin?
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Oxycontin?
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Methadone?
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Percocet, Vicodin?
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Cocaine?
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Opana?
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Morphine?
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Fentanyl?
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Dilaudid?
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Benzo's?
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Other (please specify)
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Drug use resulted in medical problems?
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Previously treated for substance dependence?
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Tried to quit on your own?
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Have you been treated by a Psychiatrist?
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Are you pregnant?
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Any family members substance dependent?
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Do you have any medical conditions?
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Currently using any medications?
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Any current legal issues we should be aware of?
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Are you currently employed?
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Describe your current living arrangements
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Accepted - Scheduled for............
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Patient denied (give reason why)
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