Application for Outpatient Services
Address Line 2
Mobile or Home Phone Number
Are you in jail or prison now?
What is your expected release date?
Were you referred?
Social Security Number
Date of birth:
Race (Choose all that apply)
African American or Black
American Indian and Alaska Native
Caucasian or White
Native Hawaiian and Other Pacific Islander
Other Single Race
None of the Other Race Categories Apply
Are you pregnant?
When is the due date
In a relationship
Do you have children?
Are you the primary caregiver
Who are they currently living with?
Open DCS Case
Are you a veteran?
What is your current educational status?
Graduate high school
Highest Grade Completed
Do you have any health problems that require special care?
Describe the medical problem
Are you vaccinated against Covid-19?
Do you have health insurance?
If HIP, provide #
Are you currently prescribed any form of Medication Assisted Treatment (MAT)?
What form of MAT have you been prescribed?
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?
Have you ever received mental health treatment?
Inpatient or Outpatient?
Are you currently receiving mental health treatment?
Provider Phone Number
Do you have a mental health diagnosis?
What is the diagnosis?
Do you take prescription drugs?
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?
Explain the pending case(s).
Are you currently on probation or parole?
Are you currently in compliance?
If yes, please provide the County and PO Name
Are you enrolled in the Recovery Works program?
With which agency?
Are you an alcoholic
Date of last drink
Are you addicted to drugs
Date of last use
Primary Drug Used
Other Drugs Used
Method of use
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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