NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE
|
|
- Arthur Marsh
- 6 years ago
- Views:
Transcription
1 New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne ON, L3K 2N7 Phone (905) Ext Fax: (905) A D M I S S I O N S I N F O R M A T I O N General Admission Information Referrals to our residential services are accepted from drug and alcohol treatment providers. New Port Centre does not accept self-referrals. For information on drug and alcohol treatment providers in your area, contact the Ontario Drug and Alcohol Registry of Treatment (DART) by phone at or visit their website ( Referrals to New Port Centre can be made by fax. To make a referral to our residential services, have your treatment provider complete and forward a New Port Centre Intake Package to our Intake Department. The Intake Package can be downloaded from our website: -health-addictions#addictions A complete referral includes the following: New Port Centre Intake package forms 1. New Port Centre Intake Form (1 page) 2. New Port Centre Medical Profile (2 pages) to be completed by a physician 3. Legal History Questionnaire 4. n-smoking Agreement 5. Photocopy of a VALID Health Card Completed Provincial Assessment Tools 6. DHQ Drug History Questionnaire 7. Adverse Consequences Questionnaire 8. Tracking Sheet With Scores of Other Assessments Please call Roberta, Intake Coordinator, at , Extension if you have any questions regarding your referral to New Port. REFERRALS WILL BE PROCESSED WITHIN SEVEN (7) WORKING DAYS FROM RECEIPT. The client will be notified after review of file. The Medical Profile Form must be completed by a physician and list all prescription and non-prescription medication (including vitamins) that the client plans to take during their residential treatment stay. When coming to New Port for residential treatment, clients should bring their valid Ontario Health Card and proof of drug benefit eligibility. We expect people attending residential treatment to be neither under the influence of non-prescribed drugs or alcohol, nor experiencing any withdrawal symptoms. If a person is assessed as being medically unstable, they will be directed to NHS withdrawal management services for assessment before admission. If a person is assessed as being under the influence of a mood-altering substance and attempts to operate a motor vehicle, we are obligated to notify the police. Revised: 05/04/13
2 Page 2 of 2 A D M I S S I O N S I N F O R M A T I O N Information For People On Methadone On admission day, please have your daily methadone drink before you arrive. Your prescription should be dated to begin the day after admission and to end on the last day of treatment. Methadone script must be faxed to Boggio Pharmacy prior to admission date. Information For Prescribing Physicians If your patient is being referred to New Port Centre residential services, please complete a Medical Profile Form for them. The Medical Profile Form must detail all prescription and non-prescription medication (including vitamins) that your patient plans to take while in residential treatment. When New Port Centre has confirmed a residential admission date for your patient, please fax an 18-day prescription for all medications to Boggio Pharmacy prior to that date. Also, please arrange for Boggio Pharmacy to receive an original copy of ANY prescriptions containing narcotics (your patient can bring this copy with them on admission day). Boggio Pharmacy will blister pack the medication and charge a dispensing fee at applicable rates. Boggio Pharmacy Phone: Catharine Street Fax: Port Colborne, ON L3K 4K8 Alternately, please have your patient s pharmacy blister pack 18 days worth of prescription medication for their residential stay. Vitamins and other non-prescription medication should be blister packed and authorized by the doctor who completes the Medical Profile Form. Information For Correctional Services Referrals New Port Centre and the Ontario Ministry of Community Safety and Correctional Services and Correctional Service of Canada co-operate to offer treatment for substance use to people involved in the correctional system. New Port Centre does not accept self-referrals. Correctional services should complete and forward a New Port Centre Intake Package with Provincial standardized assessment information to our Intake Department. In addition, signed consent to share information between New Port Centre and Correctional Services is required. When such consent is received, New Port Centre will contact Correctional Services to collect information in order to appropriately assess the person s suitability for our residential treatment program. This information includes background charges, conduct and attendance at programming during incarceration and any concerns regarding violence, anger, non-compliance or lethality. Revised: 05/04/13
3 Date Last Revised April 5, 2013 Client First Name: Client Last Name: New Port Centre Fax# (905) Referral Date / / ( D D / M M / YY) Niag ar a Health S ys tem Port Colborn e Ge ne ral Site 260 Suga rloaf Street, Port Colbor ne, ON, L3K 2N7 Phone: (9 05) E xt Fax: (9 05 ) NPC Client # Em ail: NewP ortadm in@ni a gar ah ealth. on.ca W eb: www. niaga ra hea lth.on.ca/en/mental -he alth -a ddi c tions#ad dictions I N T A K E F O R M Date of Birth: (DD MM - YY) Gender: Male / Female 1. Last Name at Birth: 2. Home Phone: ( ) 3. Address: Apt 4. City, Province: 5. Postal Code: I.D. Agency When Calling: / If : Referral Agency: Referral Agent Name: Referral Phone: ( ) Health Card #: Ethnicity: Ver: In Patient Program: Out Patient Program: Current Problem Substances # Days Used in Last Month Substances Used in Last Year (check all that apply) ne Alcohol Amphetamines Barbiturates Benzodiazepines Cannabis Cocaine Crack Crystal Meth Ecstasy Glue / Inhalants Hallucinogens Heroin / Opium OTHER Psychoactives OTC Codeine Prescription Opioids Steroids Tobacco Next of Kin: Relation: n medical Injection Drug Use (Circle 1) Next of Kin Phone: ( ) 1. Never Injected Ever Married: / 2. Injected prior to 1 year ago Current Marital Status: 3. Injected in last year Highest Education: Employment: Full Part Looking t looking Source of Income: Physical Health Legal Issues: Y/N Type: Young Offender: / Mandated Admission: / If yes: CAS / Court / Work / Family Family Doctor: Dr. Phone: ( ) Psychiatrist: Psych Dr. Phone: ( ) Taking Methadone Visual Impairment Hearing Impairment Mobility/Physical Impairment Pregnant Gambling Problem # of overnight hospitalizations last year Mental Health History Diagnosed w Diagnosed in Lifetime Hospitalized Last year Hospitalized in Lifetime Counselling/Support/Tx w Counselling/Support/Tx in Last Year Counselling/Support/Tx Ever Prescribed Medication w Prescribed Medication in Last Year Prescribed Medication - Ever Mental Health Diagnosis & Prescribed Meds: A New Port Centre Medical Profile Form must be received before an In Patient bed date is assigned
4
5 New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne, ON L3K 2N7 Phone (905) Ext Fax: (905) Web: Dear Doctor/Nurse Practitioner: Your patient has applied for admission to the residential component of treatment for treatment of his/her addiction(s) at the New Port Centre. The New Port Centre is a non-medical, non-psychiatric treatment centre for substance abuse. As a non-medical, non-psychiatric facility, we require the thorough and accurate completion of the enclosed Medical Profile to ensure that it is consistent with the medications that the client has been prescribed. For example, if a patient is taking an antidepressant, we would consider that the patient suffers from depression and that would be considered a psychiatric disorder. The list of current medications must be legible and complete on the Medical Profile form provided i.e. correct medication, correct dose, correct time and the correct route that the medication should be given. New Port addiction counsellors are non-medical personnel and it is essential that all information be complete. We have no access to psychiatric consultation other than the local emergency department; therefore we ask that clients be deemed stable with any psychiatric condition that they may have been diagnosed with, before attending New Port Centre. Inaccurate, incomplete, non-legible medical profiles will delay the intake process for your patient. Many thanks for your attention to these vital safety issues. Sincerely, Management, New Port Centre Revised: 05/04/13
6 Affix patient label here New Port Centre Niagara Health System, Port Colborne Site, 260 Sugarloaf St. Port Colborne ON Phone: Ext Fax Medical History: Please have this form completed by your health care provider Name: DOB: 1) Substance(s) use: Please briefly outline the substance(s) and pattern of use that has prompted this referral 2) Allergies: Known Allergies If yes please specify: Allergan Response 3) Diet: Does your client/patient require a special diet? If so please specify: 4) Immunization History: (te: Immunizations are not mandatory for admission) Which of the following immunizations has your client/patient received? Tetanus Year Unknown Comments Hepatitis A Series Year Unknown Hepatitis B Series Year Unknown 5) Screening History : (te: Screening is not mandatory for admission) Hepatitis B Year Unknown Comments/Results Hepatitis C Year Unknown HIV Year Unknown 6) Smoking: New Port is a non smoking program. (Clients are required to bring an eighteen day supply of a smoking cessation aid if required) n Smoker Smoker Number/Day? 1
7 7) Mental Health: Does the client/patient have a history of mental health diagnoses? Unknown If yes please specify: New Port has an affiliated psychiatrist available for consult. Please indicate if you would like your client/patient to have an appointment with the psychiatrist. If yes then please briefly outline the relevant history and the objectives of the consult. A copy of the consult will be sent to the ordering provider. Provider Name Billing Number 8) Medications: Please List all medications that your client is currently prescribed Medication Dose Frequency 9) Health: Please list any medical information including acute or chronic disorders, physical limitations etc. Provider Signature Office Stamp Print Name Client/Patient Signature Date: 2
8 Affix Patient Label New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne, ON L3K 2N7 Phone (905) Ext Fax: (905) Web: L E G A L H I S T O R Y Name: Have you ever been charged with a Federal or Provincial Offence? If yes, indicate the date and describe the offence and disposition: Date Offense (Charge) Disposition (Outcome) Are you presently on Probation or Parole? If : Start Date Expected End Date Contact your Probation/Parole Officer to complete a consent form (consent to share information) and fax it to New Port Centre Intake Department at Revised Date: JAN/14
9 Affix Patient Label New Port Centre NIAGARA HEALTH SYSTEM PORT COLBORNE GENERAL SITE 260 Sugarloaf Street, Port Colborne, ON L3K 2N7 Phone (905) Ext Fax: (905) Web: NON-SMOKING POLICY AGREEMENT 1, am aware that the New Port Centre is an (Print Name) abstinence based substance abuse treatment facility including nicotine and as a client I agree to the following: a) To respect the non-smoking policies of the New Port Centre/Niagara Health System b) To arrive for my admission date a minimum of 5 days tobacco free c) To arrive for my admission with enough Nicotine Replacement Therapy aids for my stay in residential treatment (i.e. nicotine patches, gum, lozenges or inhalers). I am aware that the decision to smoke in the building or on the property of the Niagara Health System will jeopardize my ability to remain in the program and may result in discharge from the program. I am aware that to assist me in being tobacco free the New Port Centre will offer access to acupuncture, impact of smoke inhalants education sessions, individual counselling and relaxation therapy techniques. Signature: Witness: Date: (DD/MM/YY) Revised Date: JAN/14
APPLICATION FOR Page 1/8 RESIDENTIAL TREATMENT
APPLICATION FOR Page 1/8 Instructions: The following form is required to begin the application process to Stonehenge. The form should be printed and completed by hand, then faxed or mailed to Stonehenge
More informationIf so, when: Demographic Information Male Transgender Height: Weight: Massachusetts Resident? Primary Language: Are you currently homeless?
Application Form rev. 9/09 Jeremiah's Inn P.O. Box 30035 1059 Main St., Worcester, MA 01603-0035 FAX 508.793.9568 Phone 508.755.6403 Last Name: Suffix: First Name: Middle Initial: Alias: Referral Information
More informationAPPLICATION FORM NAME:
APPLICATION FORM NAME: Application Date: Birthdate: SIN#: Requested Date for Residency: Present Address: Phone #: How long at this address? MSP #: Marital Status: Employment Status: Education: Emergency
More informationREFERRAL SOURCE GUIDELINES. Listed below is a general outline of the referral, interview and intake process at Last Door Recovery Centre.
REFERRAL SOURCE GUIDELINES Listed below is a general outline of the referral, interview and intake process at Last Door Recovery Centre. 1. Contact Last Door Recovery Centre at 1 888 525 9771 to determine
More informationTE WHARE ORANGA NGAKAU REFERRAL FORM
TE WHARE ORANGA NGAKAU REFERRAL FORM REFERRER INFORMATION REFERRAL FROM: NAME: POSITION: POST CODE: PHONE NO: FAX NO: CLIENT INFORMATION CLIENTS FULL NAME: DATE OF BIRTH: PHONE NO: POST CODE: ETHNIC GROUP:
More informationMonarch Men s Day Treatment Referral Information
Monarch Men s Day Treatment Referral Information 2018 It is important that the men sign the enclosed Release of Information, if you require updates or a discharge summary. Thank you. Men s Assessment &
More informationAdmissions Package. Mino Ayaa Ta Win Healing Centre Residential Treatment. Fort Frances Tribal Area Health Services Behavioural Health Services
Fort Frances Tribal Area Health Services Behavioural Health Services Mino Ayaa Ta Win Healing Centre Residential Treatment Admissions Package Page 1 of 13 Residential Treatment- Basic Identifying Information
More information3726 E. Hampton St., Tucson, AZ Phone (520) Fax (520)
3726 E. Hampton St., Tucson, AZ 85716 Phone (520) 319-1109 Fax (520)319-7013 Exodus Community Services Inc. exists for the sole purpose of providing men and women in recovery from addiction with safe,
More informationHAVEN WOMEN S PROGRAM APPLICATION
Hello, Thank you for your interest in the Haven of Rest Women s Ministry. We are a long-term (approximately 12 months), residential discipleship program for women with life-dominating issues. Our ultimate
More informationThe Salvation Army Homestead
The Salvation Army Homestead 975 West 57th Avenue Vancouver BC V6P 1S4 www.vancouverhomestead.ca Telephone: (604) 266-9696 Fax: (604) 266-7401 Email:homesteadintake@yahoo.ca Enclosed is the Salvation Army
More informationNOW CANADA SOCIETY TUTT STREET KELOWNA, BC V1Y 8Z5 TELEPHONE (250) FAX (250)
NOW CANADA SOCIETY 2970 TUTT STREET KELOWNA, BC V1Y 8Z5 TELEPHONE (250) 763-3876 FAX (250) 868-3876 EMAIL support@nowcanada.ca RESIDENTIAL / DAY PROGRAM REFERRAL PACKAGE THE NOW CANADA SOCIETY MISSION
More informationMedical Form. Please complete this form with your patient. Your involvement is necessary, and greatly appreciated.
PARADISE VALLEY WELLNESS CENTRE INC 3501 Paradise Valley Road, Squamish, BC Canada PO Box 1802, Garibaldi Highlands, BC V0N 1T0 Tel 604-892-3000 Fax: 604-892-3003 www.paradisevalleywellnesscentre.com Medical
More informationTop of the World Ranch Treatment Centre Admissions Information Record Demographics
1 Client Name: Date of Birth: Top of the World Ranch Treatment Centre Admissions Information Record Demographics Alias or AKA : Date: Gender: Male Female Phone #: May we leave a message? Street Address:
More informationOpioid Treatment Center Application
PLEASE FILL OUT ALL AREAS COMPLETLY Name: Date: Maiden Name or Aliases: Address: Phone: Date of Birth: SSN#: Gender: Male Female Referral Source: Phone #: Annual Family Income: SSDI SSI Other Income Insurance
More informationApplicant s Name (PRINT): Applicant s Signature: Date: Anticipated Admission Date: Time: Staff Approval: Date:
FREEDOM SUBSTANCE ABUSE TREATMENT APPLICATION/REQUIREMENTS for ADMISSION PURPOSE: Our primary goal is to facilitate a stable environment that gives individuals an opportunity to break the cycle of homelessness
More informationNIDA Quick Screen V1.0F1
NIDA Quick Screen V1.0F1 Name:... Sex ( ) F ( ) M Age... Interviewer... Date.../.../... Introduction (Please read to patient) Hi, I m, nice to meet you. If it s okay with you, I d like to ask you a few
More informationPATIENT INTAKE: MEDICAL HISTORY. Name. Address. Phone (W) (H) (C) DOB Age SS# Emergency Contact. Relationship to patient Phone
PATIENT INTAKE: MEDICAL HISTORY Name Address Phone (W) (H) (C) DOB Age SS# Emergency Contact Relationship to patient Phone Primary care physician Phone Have you ever had an EKG? Y N Date Current or past
More informationLTSR CRITERIA CHECKLIST (PLEASE PRINT LEGIBLY)
LTSR CRITERIA CHECKLIST (PLEASE PRINT LEGIBLY) Consumer s Name: Date: Person Completing Referral: Agency: Phone: Ext: Email: 18 years or older Crossroads LTSR 337 Tippecanoe Road Smock Pa, 15480 Phone:
More informationTop of the World Ranch Treatment Centre Admissions Information Record Demographics
1 Client Name: Top of the World Ranch Treatment Centre Admissions Information Record Demographics : of Birth: Health Card #: Gender: Male Female Phone #: May we leave a message? Street Address: Email Address:
More informationThe Salvation Army Homestead
The Salvation Army Homestead 975 West 57th Avenue Vancouver BC V6P 1S4 www.vancouverhomestead.ca Telephone: (604) 266 9696 Fax: (604) 266 7401 Email:homesteadintake@yahoo.ca I.L.U. Application Facilities
More informationMcLean Ambulatory Treatment Center Adult Partial Hospital and Residential Program for Alcohol and Drug Abuse 115 Mill Street Belmont, MA 02478
Alcohol and Drug Abuse Partial Hospital Program Referral Packet McLean Ambulatory Treatment Center Program Description Staffed by highly experienced psychiatrists, psychologists, social workers, nurses
More information*IN10 BIOPSYCHOSOCIAL ASSESSMENT*
BIOPSYCHOSOCIAL ASSESSMENT 224-008B page 1 of 5 / 06-14 Please complete this questionnaire and give it to your counselor on your first visit. This information will help your clinician gain an understanding
More informationHear land Men s Recovery Center
Hear land Men s Recovery Center Page 1 of 6 Please read and follow these important guidelines: 1. Complete the 5-page application. Mail or fax it back to us at the address or number above, along with copies
More informationREFERRAL FORM FOR ADMISSION TO HOMEWOOD HEALTH CENTRE
Date of Referral: REFERRAL FORM FOR ADMISSION TO HOMEWOOD HEALTH CENTRE PATIENT INFORMATION Patient Name: Date of Birth (YYYY-MM-DD): E-mail Business/Mobile Phone: Gender: Health Card #: Version Code:
More informationSpecialized Mental Health Referral Specialized Mental Health, GRT2 Grand River Hospital Freeport Site 3570 King St East, Kitchener, Ontario N2A 2W1
Specialized Mental Health Referral Specialized Mental Health, GRT2 Grand River Hospital Freeport Site 3570 King St East, Kitchener, Ontario N2A 2W1 Prior to faxing - please call the program secretary at
More informationClinical Assessment. Client Name (Last, First, MI) ID # Medicaid # DOB: Age:
Clinical Assessment Client Name (Last, First, MI) ID # Medicaid # DOB: Age: Sex: Ethnic Group: Marital Status: Occupation: Education: Multiaxial Diagnosis Axis I: Clinical Disorders / Other Conditions
More informationPhysical Issues: Emotional Issues: Legal Issues:
Men s Facility 1119 Ferry Street Lafayette, IN 47901 Phone: (765) 807-0009 Fax: (765) 807-0030 Hope Apartments 920 N 11th St. Lafayette, IN 47904 Phone: (765) 742-3246 Fax: (765) 269-9110 APPLICATION FOR
More informationDate: Dear Mental Health Professional,
Date: Dear Mental Health Professional, Attached is the Referral Form required to receive PRP services from Mosaic Community Services. The following is required to complete the application process: Completed
More informationAPPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY)
1317 w. Washington Blvd. Fort Wayne, In. 46802 260-424-2341 APPLICATION FOR ADMISSION (PLEASE PRINT CLEARLY) NAME: _ FIRST MI LAST DATE OF BIRTH: / / AGE: SOCIAL SECURITY NUMBER: LAST OR CURRENT ADDRESS:
More informationNIDA-Modified ASSIST Prescreen V1.0 1
NIDA-Modified ASSIST Prescreen V1.0 1 F Name:... Sex ( ) F ( ) M Age... Interviewer... Date.../.../... Introduction (Please read to patient) Hi, I m, nice to meet you. If it s okay with you, I d like to
More informationBuprenorphine & Controlled Substance Treatment Agreement
Buprenorphine & Controlled Substance Treatment Agreement I agree to accept the following treatment contract for buprenorphine office-based opioid addiction treatment: 1. I will keep my medication in a
More informationPSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT
DOB: / / / PSYCHIATRIC INTAKE AND TREATMENT PLAN-PART I TO BE FILLED BY PATIENT PLEASE PRINT Date Age Gender M F Current address: Married. Single Separated Divorced Widowed If patient is a child, he/she
More informationHaving the Courage to Change. Program Application. A ministry of City Gospel Mission. SS# Driver s License # City State ZIP
Having the Courage to Change A ministry of City Gospel Mission Program Application Date: Prison ID#: GENERAL INFORMATION Personal Information Name Aliases Race/Ethnicity Date of Birth SS# Driver s License
More informationNIDA-Modified ASSIST - Prescreen V1.0*
NIDA-Modified ASSIST Assessment Instrument [1] NIDA-Modified ASSIST - Prescreen V1.0* *This screening tool was adapted from the WHO Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) Version
More informationWELD COUNTY ADULT TREATMENT COURT REFERRAL INFORMATION
WELD COUNTY ADULT TREATMENT COURT REFERRAL INFORMATION Please review the attached Adult Treatment Court contract and Authorization to Share Information. Once your case has been set on the adult treatment
More informationTELEPHONE SCREENING DEMOGRAPHIC INFO
TELEPHONE SCREENING Provider Name: Provider Signature: Date: How did you hear about the hotline? DEMOGRAPHIC INFO 1 = Spouse 2 = Friend 3 = Medical Provider 4 = Flyer 5 = Parent 6 = State Hotline 7 = Physician
More informationQuestions for first-stage health assessment at reception into prison
Questions for first-stage health assessment at reception into prison A printable version of Table 1 in NICE s guideline on the mental health of adults in contact with the criminal justice system. Topic
More informationIf you do not have health insurance, the initial appointment will be $232. Follow-up appointments will be $104.
APPLICATION FOR ADMISSION TO ADDICTION MEDICINE PROGRAM AT MARQUETTE GENERAL BEHAVIORAL HEALTH SERVICES FOR BUPRENORPHINE (Suboxone) THERAPY In order to be considered for admission to the Addiction Medicine
More informationCalOMS Discharge Form Instructions
Form Instructions REQUIRED FORM: The Discharge form is a required document in the client file WHEN: This form will be created at the end of the client s treatment episode and completed in SanWITS by the
More informationHomes of Hope Application
Homes of Hope Application Name: DOB: date: Address: City: State: Zip code: SS# Phone number: email: Primary language: Secondary language: Ethnicity: Religion preference: Single: Married: Divorced: Do you
More informationBecky Nickol, NCC, LMHC Licensed Mental Health Counselor, MH Wood Lake Drive Maitland, Florida
Becky Nickol, NCC, LMHC Licensed Mental Health Counselor, MH 8569 240 Wood Lake Drive Maitland, Florida 32751 407-831-7783 becky@beckynickol.com Adult Biopsychosocial Assessment General Information Date:
More informationMedications. New Patient Registration. Billing and Insurance. Phone Calls. Prescription Refills. Lab Results and Test Results
Dear New Patient: We would like to welcome you to our practice. Our goal is to make your experience with us as pleasant as possible. In order to help us meet this goal we have listed some helpful hints
More informationBrown-Lupton Health Service Texas Christian University Campus P.O. Box Fort Worth, TX Dear Student,
Brown-Lupton Health Service Texas Christian University Campus P.O. Box 297400 Fort Worth, TX 76129 817-257-7940 Dear Student, Enclosed you will find our policies, procedures and student consent form for
More informationDear Haven Applicant: Enclosed you will find The Lake County Haven application. You may mail or fax your completed application to:
Dear Haven Applicant: Enclosed you will find The Lake County Haven application. You may mail or fax your completed application to: The Lake County Haven P.O. Box 127 Libertyville, IL 60048 Fax: 847-680-4360
More informationInitial Clinical History and Physical Form
601 E FM 544, Suite 400, Murphy, TX, 75094 TEL: 972-442-4700 Initial Clinical History and Physical Form Patient Information Name: Age: of Birth: / / Sex: Male / Female Marital Status: Single Married Divorced
More informationNICOLET COLLEGE LAW ENFORCEMENT ACADEMY BACKGROUND QUESTIONAIRE
NICOLET COLLEGE LAW ENFORCEMENT ACADEMY BACKGROUND QUESTIONAIRE Applicant s Name: Academy Applied for: Read Carefully Nicolet College Law Enforcement Academy has established admittance standards that are
More informationPATIENT INTAKE: MEDICAL AND SOCIAL HISTORY (To be completed by patient)
NAME: DOB: Today's date: PATIENT INTAKE: MEDICAL AND SOCIAL HISTORY (To be completed by patient) Use the opposite side of the page as necessary to complete your answers. Please print legibly. Patient Name
More informationBIOPSYCHOSOCIAL SCREENING ADULT
BIOPSYCHOSOCIAL SCREENING ADULT CHART NUMBER: DOB: 1. IDENTIFYING INFORMATION Client Name: Availability: Family Member Name: Availability: Family Member Phone Numbers: Telephone (Day): Telephone (Eve):
More information19 TH JUDICIAL DUI COURT REFERRAL INFORMATION
19 TH JUDICIAL DUI COURT REFERRAL INFORMATION Please review the attached DUI Court contract and Release of Information. ******* You must sign and hand back to the court the Release of Information today.
More informationSAULTEAUX HEALING & WELLNESS CENTRE INC. BOX 868 KAMSACK, SK S0A 1S0 PHONE: FAX:
SAULTEAUX HEALING & WELLNESS CENTRE INC. Email: shwc.intake-reception@sasktel.net BOX 868 KAMSACK, SK S0A 1S0 PHONE: 306.542.4110 FAX: 306. 542.3241 ADULT INTAKE/REFERRAL APPLICATION A. General Information
More informationCOMMON REFERRAL FORM
DISTRICT OF NIPISSING COMMUNITY MENTAL HEALTH AND ADDICTIONS LONG TERM SUPPORT SERVICES COMMON REFERRAL FORM Assertive Community Treatment Teams 1 and 2, North Bay Regional Health Centre ACTT 1 Phone 705-494-3031
More informationRI Health Plan 2018 Annual Report Form on Tobacco Cessation Benefits
RI Health Plan 2018 Annual Report Form on Tobacco Cessation Benefits Purpose: To collect data from each health plans fully insured accounts for policies issued in RI to insured members regardless of where
More informationAdult Education. If you have any questions, please contact the Student Health Services office at (914) , extension 2243.
Adult Education IMPORTANT! You will NOT be allowed to register for classes without providing the health information requested in this packet. The information is mandatory as required by NY State Public
More informationAdmittance and Evaluation Indemnity form
1 Admittance and Evaluation Indemnity form This needs to be completed before an individual is admitted We are a life skills centre that provides a learning environment facility PLEASE NOTE!!! We are not
More informationLUCAS COUNTY TASC, INC. OUTCOME ANALYSIS
LUCAS COUNTY TASC, INC. OUTCOME ANALYSIS Research and Report Completed on 8/13/02 by Dr. Lois Ventura -1- Introduction -2- Toledo/Lucas County TASC The mission of Toledo/Lucas County Treatment Alternatives
More informationCLIENT QUESTIONNAIRE. Preferred Name: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Relationship: Cell Phone:
CLIENT QUESTIONNAIRE Full Legal Name: DOB: / / Preferred Name: Email: Address: (Street) (City/State) (Zip Code) Home Phone: Cell Phone: Can we leave voice messages for you at these numbers? Yes Text Messages?
More informationAddictive Disorders Assessment Form
Addictive Disorders Assessment Form Thorpe Recovery Centre Telephone: 780.875.8890 Fax: 780.875.2161 Email: info@thorperecoverycentre.org CLIENT INFORMATION First Name Middle Name Last Name Phone Number
More informationPERSONAL HISTORY What are your strengths? (i.e. skills, positive qualities or characteristics) Hobbies/Extracurricular Activities (Please list): ETHNI
Date of Assessment ADULT PSYCHOSOCIAL HISTORY/INITIAL THERAPY INTAKE FORM Identifying Information: Name: Address: Age: D.O.B: Phone Number: Race: Gender: Religious Affiliation(optional): Current Household
More informationClinical Assessment. Client Name (Last, First, MI) ID # Medicaid # DOB: Age: Sex: Ethnic Group: Marital Status: Occupation: Education:
Sex: Ethnic Group: Marital Status: Occupation: Education: Multiaxial Diagnosis Axis I: Clinical Disorders / Other Conditions That May Be a Focus of Clinical Attention Diagnostic Code DSM-IV Name Axis II:
More informationPATIENT SIGNATURE: DOB: Date:
CINCINNATI PAIN PHYSICIANS, LLC (CPP) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing below, I acknowledge that I have received a copy of CPP s Notice of Privacy Practices. The Notice
More informationConsultants in Pain Medicine, P.A. Phone (210) Fax (210)
Consultants in Pain Medicine, P.A. Phone (210) 546-1480 Fax (210) 546-1489 Scott P. Worrich, M.D. Medical Center Legacy Oaks Santa Rosa Westover Hills Medical Plaza II 5368 Fredericksburg Rd 11212 State
More informationPrevention Counseling Assessment/Admission Form Reassessment / Readmission:
Prevention Counseling Assessment/Admission Form 2017-2018 Month Submitted: -OR- Month Resubmitted (After disposition completed): Counselor: 1.Target Population: Circle One Abusers Abusers/COSAPs COSAPs
More informationPATIENT INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT
PATIENT INFORMATION SHEET Referred By: Patient s Name: SSN: Date of Birth: Address: City/Zip: Phone #: Sex: M / F Marital Status: M / S / W / D No. of Dependents: Email Address: Emergency Contact Person:
More informationYMCA of Reading & Berks County Housing Application
YMCA of Reading & Berks County Housing Application Overall Eligibility Criteria To be eligible for these programs (not including SRO), applicants must be: Homeless Drug and alcohol free for at least 5
More informationOutlook and Outcomes Fiscal Year 2011
Baltimore Substance Abuse Systems, Inc. Outlook and Outcomes Fiscal Year 2011 Baltimore City Greg Warren, President Compiled July 2012 BSAS Outlook and Outcomes is the first edition of a planned annual
More informationCrossroads for Women Application
Crossroads for Women Application Application Instructions Please check the box next to the program you are applying to: The Crossroads Albuquerque, NM (must have history of homelessness) Hope House Albuquerque,
More informationCLIENT HISTORY CLIENT LEGAL NAME: CLIENT PREFERRED NAME:
CLIENT HISTORY CLIENT LEGAL NAME: DATE: CLIENT PREFERRED NAME: FAMILY & SOCIAL BACKGROUND Please list and describe your current family members (immediate, extended, adopted, etc.) and/or other members
More informationMonarch Women s Aftercare Referral Information
Monarch Women s Aftercare Referral Information January 2018 It is important that the women sign the enclosed Release of Information, if you require updates or a discharge summary. Thank you. Monarch Recovery
More informationCERTIFICATION AND AUTHORIZATION (if applicable)
10301 Democracy Lane Suite 201 Fairfax, VA 22030 Phone: 703-547-3509 Fax: 703-383-3887 www.rrpsychgroup.com Date: PERSONAL DATA please mark with an asterisk (*) your preferred mode of contact Client Name:
More informationPATIENT HISTORY DATA FORM Psychiatric, Health and Wellness, LLC 810 Michael Drive, Suite L Chesterton, IN NAME
PATIENT HISTORY DATA FORM Psychiatric, Health and Wellness, LLC 810 Michael Drive, Suite L Chesterton, IN 46304 PRINT THIS FORM, COMPLETE AND BRING WITH YOU (DO NOT COMPLETE ONLINE) : NAME: LAST FIRST
More informationChild and Youth Background Information
Child and Youth Background Information CHILD S NAME: SUBSTANCE USE HISTORY (for ages 12 and older or if applicable) Substance Type Current Use (last 6 months) Past Use: Please check and complete all that
More informationDear Applicant for Sober Living Environment Registration,
Dear Applicant for Sober Living Environment Registration, Thank you for your interest in Sober Living Registration. The California Consortium of Addiction Programs and Professionals, (CCAPP) endorses the
More informationCalOMS Admission Form Instructions
Form Instructions REQUIRED FORM: The Admission form is a required document in the client s file. Each participant s initial admission to the facility and any subsequent transfers or changes in service
More informationProgram Application for:
Prince of Peace Center P. O. Box 89 502 Darr Ave. Farrell, PA 16121 724-346-5777 www.princeofpeacecenter.org Program Application for: 1 Referred by HOPE FAITH Head of Household Information Gender Male
More informationHere are a few resources you may want to refer to in order to learn more about Applied Behaviour Analysis (ABA) and our program:
Dear Parent/Guardian: Thank you for your interest in the St.Amant Autism Programs. Please find enclosed is the application package for the St.Amant Autism Early Learning Program. Here are a few resources
More informationPERSONAL HISTORY NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP)
PERSONAL HISTORY PERSONAL INFORMATION: NAME TODAY S DATE LAST FIRST MI LIST ANY ADDITIONAL NAMES USED: ADDRESS_ PHONE (STREET) (CITY) (STATE) (COUNTY) (ZIP) AGE: DATE OF BIRTH: SOCIAL SECURITY #: RACE:
More informationTransitional House Application
St. Joseph Lily House Transitional House Application Date: Legal Name: Date of birth: Social Security #: Driver s License/CA ID # Telephone #: Message Phone#: Are you currently Married Divorced Single
More informationNeonatal Abstinence Syndrome Questions & Answers Webinar #1 (February 9, 2012) Webinar #2 (March 30, 3012)
Neonatal bstinence Syndrome Questions & nswers Webinar #1 (February 9, 2012) Webinar #2 (March 30, 3012) For more information and to download a copy of the NS Clinical Practice Guidelines, please visit
More informationClient assessment and referral
Referrals Baroona Youth Healing Place Njernda Aboriginal Corporation Client assessment and referral In order for this referral to be assessed: all sections must be completed. all information provided must
More informationAddiction Services in the Central West LHIN
Addiction Services in the Central West LHIN Helen Danakas Coordinator, Withdrawal Management Hélène (Leela Leela) Tanguay, PhD, RP, ICADC Coordinator, Narcotics Strategy Overview of Presentation Addiction
More informationThe Caring Center of Wichita LLC. General Information Client Name:
PERSONAL & SUBSTANCE ABUSE HISTORY Biological / Psychological / Social Assessment Assessors Name: Date of Assessment: General Information Client Name: Maiden (If Applicable): Date of Birth: Home Phone:
More informationMINOR CLIENT HISTORY
MINOR CLIENT HISTORY CLIENT NAME: DATE: FAMILY & SOCIAL BACKGROUND: Please list and describe your child s or teen s current family members (immediate, extended, adopted, etc.) NAME RELATIONSHIP AGE OCCUPATION
More informationDESCRIPTION OF FOLLOW-UP SAMPLE AT INTAKE SECTION TWO
SECTION TWO DESCRIPTION OF FOLLOW-UP SAMPLE AT INTAKE 7 2.1 DEMOGRAPHIC CHARACTERISTICS Table 2.1 presents demographic descriptive data at intake for those who were included in the follow-up study. Data
More informationMental Health Court Referral Checklist
Mental Health Court Referral Checklist Forms to be turned in with your referral Outagamie County Release-Please have the potential referral initial the checked boxes on the first page and sign and date
More informationMental Health Referral Form
Mental Health Referral Form Mailing Address: Niagara Region Mental Health 3550 Schmon Parkway, Second Floor, Unit 2 P.O. Box 1042 Thorold, ON L2V 4T7 905-688-2854 Toll free: 1-888-505-6074 niagararegion.ca/health
More informationOur office is located at 2030 Drew Street, Clearwater FL, We are on Drew Street, in between N.E Old Coachman Road and Hercules Avenue.
Dear New Patient, Thank you for choosing Dennis M. Lox, M.D to participate in your healthcare. We realize that you could have chosen any other office, so we are honored that you have chosen us. While Dr.
More informationEXODUS HOMES RESIDENT APPLICATION
EXODUS HOMES RESIDENT APPLICATION ADMISSION DATE: RELEASE DATE: OPUS #: APPROVED APPLICANT NOTIFIED DENIED APPLICANT NOTIFIED NAME: ADDRESS: CITY: STATE ZIP CODE HAVE YOU EVER BEEN A RESIDENT OF CATAWBA,
More informationCalOMS Admission. Page 1 of 6
CalOMS Form All fields (unless labeled optional) must be completed CalOMS Admission Client Profile Client First Name Provider Client ID (optional) Client Last Name SSN - - Middle Initial Drivers License
More informationCOMPASS RECOVERY OPIOID REHABILITATION PROGRAM QUESTIONAIRE FOR PROSPECTIVE OPIOID REHABILITATION. Name Birthdate / /
COMPASS RECOVERY OPIOID REHABILITATION PROGRAM QUESTIONAIRE FOR PROSPECTIVE OPIOID REHABILITATION Name Birthdate / / Home phone ( ) - Cell phone ( ) - Please answer the following questions which will help
More informationRECOVERY PROGRAM INFORMATION AND REFERRAL FORM
* Note: For the Men s Recovery Program, at this time, we are accepting 1) Fayette county court-ordered clients, 2) clients referred by the KY Department of Corrections, 3) clients referred by Fayette Co.
More informationMassHealth Tobacco Cessation Program Benefit
MassHealth Tobacco Cessation Program Benefit Fact Sheet for Providers Overview of the New Benefit Effective July 1st, 2006, MassHealth members (Medicaid recipients in Massachusetts) have access to tobacco
More informationConcurrent Disorders Support Services Application Form
Concurrent Disorders Support Services Application Form Concurrent Disorders Support Services Client Treatment Consent to the Collection, Use and Disclosure of Personal Information To protect your privacy,
More informationINFORMATION SHEET FOR THE DEPARTMENT OF PAIN AND PALLIATIVE CARE
INFORMATION SHEET FOR THE DEPARTMENT OF PAIN AND PALLIATIVE CARE Please review the following instructions as it contains important information regarding the management of your pain. Once reviewed, our
More informationPARTICIPATION APPLICATION and AGREEMENT for CULINARY SCHOOL PROGRAM
Page 1 PARTICIPATION APPLICATION and AGREEMENT for CULINARY SCHOOL PROGRAM PERSONAL INFORMATION First Name Middle Initial Last Name Current Street Address City State Zip code ( ) CELL _( )_HOME @ Email
More informationTHE REGIONAL MUNICIPALITY OF NIAGARA REQUEST FOR PRE-QUALIFICATION (RFPQ) OF
THE REGIONAL MUNICIPALITY OF NIAGARA REQUEST FOR PRE-QUALIFICATION (RFPQ) OF CESSATION SUPPORT AND NICOTINE REPLACEMENT THERAPY TO RESIDENTS IN THE COMMUNITY DOCUMENT NUMBER# ISSUE DATE: WEDNESDAY OCTOBER
More informationSACRED HEART HOSPITAL 421 Chew Street Allentown, PA EAC REFERRAL PACKET REQUIREMENTS
EAC REFERRAL PACKET REQUIREMENTS Please refer to the following in order to adhere to the standard requirements for the referral packet submission to Sacred Heart Hospital EAC: Case Management - Name -
More informationPatient Agreement for the use of Opioid Medications
today s date Patient Name date of birth Patient Agreement for the use of Opioid Medications The purpose of this agreement is to give you information about the medications that may be part of your treatment
More informationPatient Application for Treatment
Address: 179 Linwood Ave. Colchester, CT 06415 Phone: (860) 603-3541 Fax: (860) 603-3544 Visit Date: / / MR#: Patient Application for Treatment 1. Name: 2. Date of Birth: 3. Social Security #: 2. Address:
More informationRECOVERY APPLICATION The Foundry Ministries
RECOVERY APPLICATION The Foundry Ministries PERSONAL FIRST NAME MIDDLE NAME LAST NAME LAST PHYSICAL STREET ADDRESS CITY STATE ZIP CELL EMAIL ADDRESS DEMOGRAPHICS GENDER ETHNICITY AGE MARITAL STATUS SINGLE
More informationMarriage, Family, and Individual Counselling PROGRAMS AND SERVICES
C O U N S E L L I N G Marriage, Family, and Individual Counselling 2018 2019 PROGRAMS AND SERVICES BEAVER LAKE COUNSELLING SERVICES WELCOME TO BEAVER LAKE COUNSELLING SERVICES! This information packet
More information