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Today's Date
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Referring Agency Contact Person
Referring Contact Phone
Treatment Type Request
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Inpatient- Clinical Stabilization Services
Outpatient- Intensive Outpatient Program
Outpatient- General Counseling
Select Service Type for Substance Addiction Treatment.
Client Information
Client Name
Social Security Number
*
Date of Birth
MM slash DD slash YYYY
Sexual Identity
Massachusetts Resident?
Yes
No
Veteran?
Yes
No
Housing Status?
Homeless
Nearly Homeless
Permanent Residence
Insurance Provider
Insurance Policy Number
Does Client Have Picture ID?
Yes
No
Does Client Have A MassHealth Card?
Yes
No
Primary Language
If other than English
Pregnant?
Yes
No
If yes, Anticipated Delivery Date?
Legal History
Does Client have Legal Action pending?
Yes
No
If yes, what are the charges?
Does Client have Outstanding Warrant?
Yes
No
If yes, explain
Does Client have Any Current Charges?
Yes
No
Is Client on Probation?
Yes
No
Is Client on GPS Monitoring?
Yes
No
Has Client Been Convicted of Arson?
Yes
No
Has Client Been Convicted of a Sexual Offense?
Yes
No
Substance Use History
List Drug Use in Order of Priority/ Drug of Choice
Drug
Date of Last Use
Amount Used
Method of USe
Medical History
Stopped Taking Any Medications in Past Six Months?
Yes
No
If Yes, What?
Acute, or Chronic, Medical or Dental Needs?
Yes
No
If Yes, What?
Disabilities?
Yes
No
If Yes, List Special Accommodations Needed?
On Methadone/ Suboxone/ Vivitrol?
Yes
No
If Yes, Explain.
History
History of Mental Health Diagnosis?
Yes
No
If yes, explain
History of Assault?
Yes
No
If yes, explain
History of Harm to Self or Others?
Yes
No
If yes, explain
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