subject_line
Application for Outpatient Services
Date
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First Name
Middle Name
Last Name
Street Address
Address Line 2
City
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
County
Mobile or Home Phone Number
Email Address
Age
Gender
Male
Female
Other
Are you in jail or prison now?
Yes
No
What is your expected release date?
Were you referred?
Yes
No
Referred By
Social Security Number
🛈
Date of birth:
+
Race (Choose all that apply)
African American or Black
American Indian and Alaska Native
Asian
Caucasian or White
Native Hawaiian and Other Pacific Islander
Other Single Race
None of the Other Race Categories Apply
Are you pregnant?
Yes
No
When is the due date
Marital Status
Single
Married
Separated
Divorced
In a relationship
Do you have children?
Yes
No
Are you the primary caregiver
Yes
No
Who are they currently living with?
Me
Open DCS Case
With family/friends
Adopted out
Are you a veteran?
Yes
No
What is your current educational status?
Graduate high school
GED
Some College
College Degree
Other
Highest Grade Completed
Do you have any health problems that require special care?
Yes
No
Describe the medical problem
Are you vaccinated against Covid-19?
Yes
No
Do you have health insurance?
Yes
No
If HIP, provide #
Are you currently prescribed any form of Medication Assisted Treatment (MAT)?
Yes
No
What form of MAT have you been prescribed?
Suboxone
Sublocade
Methadone
Naltrexone
Vivitrol
Other
Explain
What is your current dosage
How long have you been prescribed MAT?
Please provide the name and contact information of the prescribing physician.
Have you ever tried to commit suicide?
Yes
No
When?
Have you ever received mental health treatment?
Yes
No
Inpatient or Outpatient?
Inpatient
Outpatient
Are you currently receiving mental health treatment?
Yes
No
Provider
Provider Phone Number
Do you have a mental health diagnosis?
Yes
No
What is the diagnosis?
Do you take prescription drugs?
Yes
No
List the drug(s) and the reason(s) they've been described
How many times have you been arrested?
Do you have any court cases pending?
Yes
No
Explain the pending case(s).
Are you currently on probation or parole?
Yes
No
Are you currently in compliance?
Yes
No
If yes, please provide the County and PO Name
Are you enrolled in the Recovery Works program?
Yes
No
With which agency?
Are you an alcoholic
Yes
No
Date of last drink
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Are you addicted to drugs
Yes
No
Date of last use
+
Primary Drug Used
Other Drugs Used
Method of use
Ingested
Smoked
Intravenous
Age of First Use
How long is the longest period of sobriety in the past.
List all outpatient drug and alcohol programing/treatment you have participated in: (12-step, drug court, IOP)
Do you have anything else you'd like to tell us?
I agree to allow the staff of Next Step to discuss my background and treatment with other professionals and agencies.
I understand for the protection of myself and others there may be a need for the Board of Directors or the staff of Next Step to check on my legal standing and criminal background.
I also understand that I am giving permission for the staff of Next Step to contact any and/or all names and facilities on this application.
I have read all the questions and answered them honestly.
I agree to not use non-prescribed drugs, consume alcohol or violate the law while attending Next Step courses.
I agree to stay current with my service fees.
I agree to attend all required classes.
I agree to these conditions because recovery from drug and / or alcohol addiction is important to me.
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