Patient/Contact Information

(*) Fields are required.

* First Name: Middle Name: * Last Name: Address: * City: * State: * Zip Code: * Phone Number: Email Address: * Relation to Patient:

Identification

Social Security Number: If no SSN, give reason why: Drivers License/State ID: No Driver's License/State ID Number, provide reason why:

Additional Information

* DOB: (mm/dd/yyyy) * Gender: Select One Male Female Marital Status: Select One Single Divorced Married Widowed/Remarried Ethnic Group: Select One African/American Arabic Asian Caucasian/European East European Hispanic/Spanish Native American

Insurance Information

Do you have coverage? Select One Yes No Are you covered under someone else's policy? Select One Yes No Insurance Company: Blue Care Network Blue Cross Connecticut General Medicare Medicare Managed Care Value Options/Priority Health Private pay/no insurance Other Insurance State in which you have insurance: AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VA WA WV WI WY Insurance Contact Number: Member Policy Number: Insurance Group Number: Insurance Plan: Effective Date: If your insurance is in another name, please provide the information below: Insured Name: Relation to Patient: Date of Birth: (mm/dd/yyyy) Still Employed? Select One Yes No Termination Date: (mm/dd/yyyy)

Addictions

* First Substance of Choice: Select One Alcohol Heroin Prescription Narcotics Cocaine Crack Cocaine Benzodiazepines Marijuana Amphetamine How long have you used this substance? Select One 1 to 6 months 6 months to 1 year 1 to 5 years 5 to 10 years 10+ years How often do you use? Select One Daily 1-2 times weekly 3-6 times weekly 1-3 times monthly Date of last use: Select One Today Yesterday Past Week Within the Last Month   Second Substance of Choice: Select One Alcohol Heroin Prescription Narcotics Cocaine Crack Cocaine Benzodiazepines Marijuana Amphetamine How long have you used this substance? Select One 1 to 6 months 6 months to 1 year 1 to 5 years 5 to 10 years 10+ years How often Do You Use? Select One Daily 1-2 times weekly 3-6 times weekly 1-3 times monthly Date of Last Use: Select One Today Yesterday Past Week Within the Last Month   Third Substance of Choice: Select One Alcohol Heroin Prescription Narcotics Cocaine Crack Cocaine Benzodiazepines Marijuana Amphetamine How long have you used this substance? Select One 1 to 6 months 6 months to 1 year 1 to 5 years 5 to 10 years 10+ years How often do you Use? Select One Daily 1-2 times weekly 3-6 times weekly 1-3 times monthly Date of Last Use: Select One Today Yesterday Past Week Within the Last Month   Previous Treatment Experience Please include inpatient and outpatient treatments Have you had prior treatment? dd_had_treatment Select One Yes No 1. Name of Program: Select One Inpatient Chemical Dependency Outpatient Chemical Dependency Inpatient Psychiatric Outpatient Mental Health Date of treatment:   2. Name of Program: Select One Inpatient Chemical Dependency Outpatient Chemical Dependency Inpatient Psychiatric Outpatient Mental Health Date of treatment: Additional Questions Have you ever: Had thoughts of killing yourself? Select One Yes No If so when? Attempted suicide? Select One Yes No If so when? If you answered yes to any of the above, were you under the influence at the time? Select One Yes No If you were under the influence, which substance? Are you currently being treated for any medical problems? Select One Yes No Describe problem: Optional information How did you hear about HTC/Harbortown Treatment Center?