Application for Outpatient Services

Are you in jail or prison now?
Were you referred?
Race (Choose all that apply)
Are you pregnant?
Marital Status
Do you have children?
Are you the primary caregiver
Who are they currently living with?
Are you a veteran?
What is your current educational status?
Do you have any health problems that require special care?
Are you vaccinated against Covid-19?
Do you have health insurance?
Are you currently prescribed any form of Medication Assisted Treatment (MAT)?
Have you ever tried to commit suicide?
Have you ever received mental health treatment?
Inpatient or Outpatient?
Are you currently receiving mental health treatment?
Do you have a mental health diagnosis?
Do you take prescription drugs?
Do you have any court cases pending?
Are you currently on probation or parole?
Are you currently in compliance?
Are you enrolled in the Recovery Works program?
Are you an alcoholic
Are you addicted to drugs
Method of use
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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