INITIAL CONTACT AND SCREENING

Initial Contact Data

How did you hear about us?

If Referred, by who?

Caller is interested in help for:

Reason for your call:

DISPOSITION

Medical Counseling Information Only Refer Out

SCREENING FOR ADMISSION

Name of person to receive services:

Presenting Factor for Treatment Now

Substances Currently Being Used

If None continue to 'Prior Substance Abuse Treatment?' Section

Step Down from Detoxification:

Yes No

Detox Needed?

Yes No

Prior Substance Abuse Treatment?

Yes No

If 'No' continue to 'Any History of Mental Health Issues' Section

Any History of Mental Health Issues?

Yes No

if Yes please describe:

Legal Issues (past or current)

== == = Eligibility of Services = == ==

Eligibility of Services

Physically stable: No evidence of withdrawals symptoms and/or physical concerns which would interfere with the the therapeutic process. Psychiatric condition is stable, but stress dependents behaviors threaten work, family, and social domains. Treatment Acceptance/Resistance: External and/or internal motivation for treatment is present. Continued Use: Able to control use with active participation in outpatient services and self-help. Stable living environment. Client able to participate in Tele-health services.

== == = Financial Eligibility= == ==

Can individual/family meet financial requirements of treatment?

Yes No

if Yes, How:

Insurance Self-Pay Contract

Person Responsible for payment:

Relationship to Client

Insurance Information:

Address Affiliated With Insurance Plan

Can Tele Med Clinix meet the treatment needs of this individual?

Yes No

If, Referred Out - Facility Name

INITIAL CONTACT AND SCREENING

Initial Contact Data

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SCREENING FOR ADMISSION

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If None continue to 'Prior Substance Abuse Treatment?' Section

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If 'No' continue to 'Any History of Mental Health Issues' Section

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Person Responsible for payment:

Insurance Information:

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Onboarding Status:

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