Outpatient Treatment Application Form

Step 1 of 14

Choose Which Office You Are Contacting*
- Wasilla
- Fairbanks
Are you interested in Withdrawal Management Services?
- Yes
- No
What substances are you currently using?
When was your last use?
MM slash DD slash YYYY
How much are you using and how are you using (smoking, injection, snorting)?
Consent To Treat Contract
I, the undersigned, do hereby acknowledge that:*
First Last
1. I have voluntarily consented to become a client of True North Recovery Inc and that this voluntary consent is true, regardless of the fact that I may be court ordered to the program.
2. I understand that all things spoken about in group are confidential and should not be shared with anyone outside of treatment. I will respect all participants confidentiality.
3. I am aware that True North Recovery Inc is a chemical dependency/mental health treatment program. The general outline, purpose, and methods of treatment offered by True North Recovery Inc has been approved by the Alaska Department of Behavioral Health and is evidenced based curriculum and practices. “ I agree to participate
4. I further understand that part of my treatment at True North Recovery Inc may require me to submit urine samples for analysis of drug content. Further requirements may include psychological, psychiatric, or general health testing, disclosure, and monitoring of prescribed medications. I consent to undergo these procedures.
5. I acknowledge and understand that no promise or guarantees have been made to me regardless of the outcome of my treatment by True North Recovery Inc and do hereby absolve True North Recovery Inc from liability in the event my treatment is unsuccessful.
6. I hereby agree to comply with and abide by the policies, rules, and regulations of True North Recovery Inc in my treatment.
Check Box To Agree To Terms (Required to Proceed)*
I have read each paragraph contained above and have had the opportunity to clarify questions I have regarding these. Accordingly, I acknowledge that I duly understand the provisions of the document and its legal consequences.
FEES FOR SERVICE:
1. I agree to pay the cost of my treatment. I will make arrangements with the Financial Office before starting my treatment program.
2. I acknowledge that all fees for services are due and payable at the time of service unless other arrangements have been made.

ATTENDENCE:
1. I agree to be on time for all scheduled groups and counseling sessions. I understand that if I am late I may not be admitted to the group session.
2. Subject to ongoing assessment and evaluation of my treatment progress, I may expect changes in the level and duration of services while I am enrolled. Further, I may expect these changes to be discussed by the treatment team and any modifications will be in the best interest of my treatment.
3. My attendance at other support groups such as Alcoholics Anonymous, Narcotics Anonymous, Adult Children of Alcoholics, etc. may be required of me as determined by the treatment team.

ABSTINENCE:
1. Abstinence from non-prescribed, mind/mood altering chemicals (including alcohol) is clearly the primary goal of this program, unless contraindicated by my assessed special needs. Therefore, I agree to maintain abstinence from these chemicals while in treatment. My failure to comply with this abstinence policy will result in an immediate re-evaluation of my treatment needs and may result in termination from this program.
Check Box To Consent To Terms (Required to Proceed)*
I have read and agree to comply with the above contract for treatment.
Client Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Client Signature*
Date
MM slash DD slash YYYY
Counsellor Signature
Date
MM slash DD slash YYYY

Financial Responsibility Agreement
If you come in to sign up for a treatment program you must provide proof of your household gross income at your financial appointment. Your financial contract must be completed before you begin treatment.
Ultimately you, the client, are responsible for payment of all services.
• If you have INSURANCE please bring your insurance ID card, or insurance form with patient portion completed and signed. We will gladly bill your insurance. If your insurance does not cover any portion of your costs you will then become eligible for the sliding fee scale. You may want to call your insurance company or look in your policy to determine if your insurance covers the treatment you are about to begin.
• If you are covered by MEDICAID OR DENALI KID CARE please bring in your sticker, coupon, or card covering the current month. If Medicaid does not cover any portion of your costs you will then become eligible for the sliding fee scale. You will then become responsible for payment.
If you DO NOT have Insurance, Medicaid, or Denali Kid Care you must bring your most recent TAX RETURN, W-2, and 1099 (if applicable) And any of the following that apply:
• LAST TWO CHECK STUBS (IF MARRIED SPOUSES ALSO)
• UNEMPLOYMENT
• WORKMANS COMPENSATION
• SOCIAL SECURITY INCOME
• RETIREMENT PENSION
• DISABILITY INCOME
• PUBLIC ASSISTANCE
• NATIVE CORPORATION DIVIDENDS

If you do not provide adequate proof of income you will be charged at our customary full rate.
Client Name*
First Last
Client Signature*
Date
MM slash DD slash YYYY
Guardian Signature (Live signature required)
Date
MM slash DD slash YYYY

CONTACT PREFERENCES
I request/authorize True North to disclose information to and/or obtain information regarding myself using the following contact information.
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Mailing Address*
Street Address City State / Province / Region ZIP / Postal Code Country
Email
Main Phone Number*
TNR will leave a voice or text message at this number.
Fax Number ( If Applicable )
Please list all other numbers that we may use to contact you.
Alternate Contact #1
First Last
Relation
OK To Leave a Message?
- Yes
- No
Alternate Contact #2
First Last
Relation
OK To Leave a Message?
- Yes
- No
Alternate Contact #3
First Last
Relation
OK To Leave a Message?
- Yes
- No
Alternate Contact #4
First Last
Relation
OK To Leave a Message?
- Yes
- No
When signing below, I attest to the following.
I understand that the information in this correspondence may contain information relating to my substance us diagnosis and/or treatment, mental health diagnosis and/or treatment, and/or Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS)
I understand that my alcohol and/or drug treatment records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Patient Records, 42 C.F.R. Part 2, and the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that the agencies identified above may not condition my treatment on whether I sign a consent form, but that in certain circumstances I may be denied treatment if I do not sign a consent form.
I understand and consent to the use of all electronic communication, text messaging and email and that they all have potential security risks.
Client Name*
First Last
Client Signature*
Date*
MM slash DD slash YYYY
Parent/Guardian/Representative Name
First Last
Parent/Guardian/Representative Signature
Date
MM slash DD slash YYYY
Witness Name*
First Last
Witness Signature*
Date*
MM slash DD slash YYYY
DISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION
I UNDERSTAND THAT MY ALCOHOL AND/OR DRUG TREATMENT RECORDS ARE PROTECTED UNDER THE FEDERAL REGULATIONS GOVERNING CONFIDENTIALITY AND DRUG ABUSE PATIENT RECORDS, 42 C.F.R. PART 2, AND THE HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT OF 1996 ("HIPAA"), 45 C.F.R. PTS 160 AND 164, AND CANNOT BE DISCLOSED WITHOUT MY WRITTEN CONSENT UNLESS OTHERWISE PROVIDED FOR BY THE REGULATIONS.
I UNDERSTAND THAT I MAY BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR THE PURPOSES OF TREATMENT, PAYMENT OR HEALTH CARE OPERATIONS, IF ALLOWED BY STATE LAW. I WILL NOT BE DENIED SERVICES IF I REFUSE TO CONSENT TO A DISCLOSURE FOR OTHER PURPOSES.
I HAVE HAD EXPLAINED TO ME AND FULLY UNDERSTAND THIS REQUEST/AUTHORIZATION TO RELEASE AND/OR OBTAIN RECORDS AND INFORMATION, INCLUDING THE NATURE OF THE RECORDS, THEIR CONTENTS, AND THE CONSEQUENCES AND IMPLICATIONS OF THEIR RELEASE. I UNDERSTAND THAT ONCE MY INFORMATION IS RELEASED, TNR CANNOT PREVENT THE REDISCLOSURE OF THAT INFORMATION, HOWEVER DOES PROVIDE A STATEMENT OF PROHIBITION AGAINST REDISCLOSURE OF PROTECTED HEALTH INFORMATION WITH DISCLOSURES MADE.
I UNDERSTAND THAT I MAY REVOKE A CONSENT IN WRITING AT ANY TIME, EXCEPT TO THE EXTENT THAT ACTION BASED ON THIS CONSENT HAS ALREADY BEEN TAKEN. SEE RECEPTION FOR INSTRUCTIONS TO REVOKE A CONSENT. IF TREATMENT IS MANDATED AS PART OF PROBATION REQUIREMENTS, A CONSENT MAY NOT BE REVOKED UNTIL CONDITIONS OF PROBATION ARE MET OR PROBATION ENDS.
I HAVE A RIGHT TO RECEIVE A COPY OF THIS SIGNED AUTHORIZATION. I ALSO UNDERSTAND THAT UPON MY WRITTEN REQUEST, TNR MUST PROVIDE A RECORD OF DISCLOSURES MADE FOR LEGAL, ADMINISTRATIVE OR QUALITY ASSURANCE PURPOSES.
NOTICE

PROHIBITING REDISCLOSURE OF ALCOHOL AND DRUG TREATMENT INFORMATION
Name
First Last
Signature
Date
MM slash DD slash YYYY

Client Notice
This notice describes how medical and drug and alcohol related information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
General Information: Information regarding your health care, including payment for health care, is protected by two federal laws: The Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 42 U.S.C. 1320d et seq., 45 C.F.R. Parts 160 & 164, and the Confidentiality Law, 42 U.S.C. 290dd-2, 42 C.F.R. Part 2. Under these laws, True North Recovery Inc. (TNR) may not say to a person outside TNR that you attend the program, nor may TNR disclose any information identifying you as an alcohol or drug abuser or disclose any other protected information except as permitted by federal law.
True North Recovery Inc. must obtain your written consent before it can disclose information about you for payment purposes. For example, TNR must obtain your written consent before it can disclose information to your health insurer in order to be paid for services. Generally, you must also sign a written consent before TNR can share information for treatment purposes or for health care operations. However, federal law permits TNR to disclose information without your written permission:
1. Pursuant to an agreement with a qualified service organization/ business associate;
2. For research, audit or evaluations;
3. To report a crime committed on TNR’ premises or against TNR personnel;
4. To medical personnel in a medical emergency;
5. As allowed by an authorizing court order.
6. Physical or sexual abuse or neglect committed against a child or elderly person
7. Suicidal or homicidal threats or attempts
8. Internal Communications

For example, TNR can disclose information without your consent to obtain legal or financial services, or to another medical facility to provide health care to you, as long as there is a qualified service organization/business associate agreement in place.
Before TNR can use or disclose any information about your health in a manner which is not described above, it must first obtain your specific written consent allowing it to make the disclosure. Any such written consent may be revoked by you in writing.
YOUR RIGHTS Under HIPAA you have the right to request restrictions on certain uses and disclosures of your health information. TNR is not required to agree to any restrictions you request, but if it does agree then it is bound by that agreement and may not use or disclose any information which you have restricted except as necessary in a medical emergency.
You have the right to request that we communicate with you by alternative means or at an alternative location. TNR will accommodate such requests that are reasonable and will not request an explanation from you. Under HIPAA you also have the right to inspect and copy your own health information maintained by TNR, except to the extent that the information contains psychotherapy notes or information compiled for use in a civil, criminal or administrative proceeding or in other limited circumstances.
Under HIPAA you also have the right, with some exceptions, to amend health care information maintained in TNR’ records, and to request and receive an accounting of disclosures of your health-related information made by TNR during the seven years prior to your request. You also have the right to receive a paper copy of this notice. TNR may deny a client request for amendment if it determines that the information or record:
• Was not created by an TNR employee
• Is not part of a designated record set
• Is accurate and complete

A client, whose request for amendment is denied, may pursue the next appropriate level of the client grievance procedure.
TNR’ Duties TNR is required by law to maintain the privacy of your health information and to provide you with notice of its legal duties and privacy practices with respect to your health information. TNR is required by law to abide by the terms of this notice. TNR reserves the right to change the terms of this notice and to make new notice provisions effective for all protected health information it maintains. Any revisions to this policy will be distributed to you at your next scheduled session or appointment.
Complaints and Reporting Violations You may complain to TNR and the Secretary of the United States Department of Health and Human Services if you believe that your privacy rights have been violated under HIPAA. You may file a complaint if you believe your privacy rights have been violated by completing a complaint form (available at the front desk) and following the steps of the Grievance Procedures. You will not be subject to retaliation for filing such a complaint.
A violation of the Confidentiality Law by a program is a crime. Suspected violations of the Confidentiality Law may be reported to the United States Attorney in the district where the violation occurs.
Contact For further information, contact TNR by telephoning 907-313-1333 Effective Date 7/2018
Check Box To Acknowledge (Required To Proceed)*
I hereby acknowledge that I received a copy of this notice.
Patient Signature*

Date*
MM slash DD slash YYYY

Guardian Signature (Live signature required)

Email

Date
MM slash DD slash YYYY

Client Profile

Name*
First Last
Today's Date*
MM slash DD slash YYYY

Client Gender*

Male

Female
If female, maiden name required*

Current Address*
Street Address City State ZIP Code

Permanent Address*
Street Address City State ZIP Code

Best Contact Phone*
Alternate Phone
Email*

Date Of Birth*
Month
Day
Year

What is your preferred form of contact?*

Where were you born?*

Social Security Number*

Medicaid Number

Demographics

Ethnicity: Check One*

Not Spanish/Hispanic/Latino

Chicano

Cuban

Hispanic-not otherwise specified

Mexican American

Puerto Rican

Spanish/Hispanic/Latino

Not Collected

Unknown
Race(s): Check All That Apply*
Aleut
American Indian
Asian
Athabascan (Other than American Indian)
Black/African American
Caucasian
Haida
Inupiat
Native Hawaiian
Other
Other Alaska Native
Pacific Islander
Refused
Tlingit
Tsimshian
Yupik
Not Collected
Unknown
Veteran Status: Check One*

Never in Military

Vietnam Vet; combat

Vietnam Vet; no combat

Gulf War Vet; combat

Iraq War Vet; combat

Afghan War Vet; combat

Active duty combat

Active duty no combat

Reserves/Nat. Guard; combat

Reserves; no combat

Retired from Military; combat

Retired Military; non-combat

Veteran other eras

Military Dependent

Not Applicable

Not Collected

Unknown
Sexual Orientation:

asexual

bisexual

heterosexual

homosexual
English Fluency:*

Excellent

Good

Moderate

Poor

Not At All

Interpreter Needed
Current U.S. Citizen?*

Yes

No
Dual Citizenship?*

Yes (If yes describe below)

No
Define Dual Citizenship*

Special Needs:*
Acquired Brain Injury
Autism
Developmentally Disabled
Fetal Alcohol Spectrum Disorder
Major Difficulty in Ambulating or Nonambulation
Moderate to Severe Medical Problems
New Immigrant
Organically Based Problem
Severe Hearing Loss or Deaf
Traumatic Brain Injury
Visual Impairment or Blind
Alcoholism
Drug Abuse
Mental Health Issues
HIV/AIDS
Other
Sex Offender Registry
SO Priority Population
Unkown
General Client Comments:

Intake Information

1. File Location: Where will client be admitted? (To be filled out by Staff)

2. Intake Staff (To be filled out by Staff)

3. Initial Contact: Check One

Phone

Drop In (Orientation)

Hospital / On Call Intervention

Emergency Outreach Intervention

Community Service Patrol

By Appointment

Mail or Fax

Other
4. Where client currently lives (city):*

5. Intake Date (To be filled out by Staff)

6. Source of Referral:*

7. Only required if FEMALE: Pregnant?

Yes

No

Unknown
8. Injection Drug User: (Within the past 6 months)*

Yes

No
9. What do you consider your number one problem: (Specify From List Below)*
What do you consider to be your second problem: (Specify from list below)*
What do you consider to be your third problem: (Specify from list below)*
10. Presenting Problem(s) in your own words: (Why are you seeking services?)*
Special Initiative: Check All That Apply
None
Anchorage Coordinated Resource Project
Anchorage Family Dependency Court
Anchorage Municipal Wellness Court
Anchorage Veteran’s Court
APIC (Assess, Plan, Identify, & Coordinate)
Bethel Therapeutic Court
BTKH – Parenting with Love and Limits
BTKH – Transition to Independence Process
CASII – Matrix
CASII – PLL
CASII – TIP
Disasters
DVSA – Victim Services
Anchorage Felony Drug Court
Anchorage DUI Court
Fairbanks Juvenile Treatment Court
Fairbanks Wellness Court
Juneau Coordinated Resource Project
Juneau DUI Court
Ketchikan Therapeutic Court
Methadone
Palmer Coordinated Resource Project
Psychiatric Emergency Services
Traumatic Brain Injury
Therapeutic Courts
Women w/Children

Collateral Contacts

Name
First Last
Relation

Address
Street Address City State ZIP Code

Home Phone
Work Phone
Cell Phone
Other
Can We Contact?

Yes

No
Consent On File?

Yes

No
Name
First Last
Relation

Address
Street Address City State ZIP Code

Home Phone
Work Phone
Cell Phone
Other
Can We Contact?

Yes

No
Consent On File?

Yes

No
Who referred you to our agency? (Specify Agency and Name of Person)*

Why are you seeking services at our agency?*

In your own words, what problem(s) would you like our agency to help you with?*
Have you ever received services from our agency?*

Yes

No
If yes, when and what type of services did you receive?
Are you currently receiving mental health and/or substance abuse treatment services from any other agency?*

Yes

No
If yes, which agency and what type of services did you receive?

Life Domains/Client Status

1. Date*
MM slash DD slash YYYY

2. Domains: Can Select Both*
Substance Abuse
Mental Health

3. Client Type (To be filled out by Staff)

4. Are you currently prescribed Methadone, Suboxone or Subutex?*

Yes

No
5. # of Prior Substance Abuse Treatment:*

6. # of Non-treatment Related Hospitalizations in Past 6 Months:*

7. # Of times the client has attended a self-help program in the 30 days preceding the date of admission to treatment services. Includes attendance at AA, NA, and other self-help/mutual support groups focused on recovery from substance abuse and dependence: Check One*

No attendance in the past month

1-3 times in past month

4-7 times in past month

8-15 times in past month

16-30 times in past month

Some attendance in past month, but frequency unknown

Unknown

Not Collected

Life Domains/Education

Education Status: Check one*

No Schooling

If K-11 List How Many Years in Box Below

General Education Degree (GED)

High School Diploma (not GED)

Vocational Training beyond High School

Special Ed Ungraded Classes

Baccalaureate Degree (BA, BS)

Graduate work (no degree)

Master’s degree

Doctorate/Professional degree

Post-Secondary 1 yr

Post-Secondary 2 yrs.

Post-Secondary 3 yrs.

Post-Secondary 4+ yrs. (no degree)

Other

Unknown

Not Collected
If K-11 List How Many Years Here

School Attendance Status: Check One*

Unknown

Not Collected (SA Clients only)

Not applicable – MH client age less than 3 or

greater than 17 (except for young adults 18-21

protected by IDEA)

Attending School

Not in School

Life Domains/Financial/Household Information

Employment Status: Check One*

Disabled

Employed Full Time

Employed Part Time

Homemaker

Armed Forces

No Response

Not Collected

Not in Labor Force/Other

Not Seeking Work

Other

Resident/Inmate

Retired

Seasonal Employee/in season

Seasonal Employee/out season

Student

Unemployed/Not seeking work

Unemployed/Subsistence

Unemployed/Looking for work

Unknown
Source of Income: Check One*

Alaska Native Corp Dividends

Alimony

Alaska PFD

Child Support

Employment

Interest and Other

None

Other

Public Assistance/Welfare Pay

Parent's Income

Railroad Retirement

Retirement, Survivor, Disability Pension

Social Security Disability (SSDI)

Self-Employment

Supplemental Security Ins (SSI)

SSI/SSDI Never

SSI/SSDI Previous

Spouse's or Significant Other's Income

Social Security

Tribal Assistance Programs

Unemployment Compensation

Unknown

Not Collected
Health Insurance Type: Check One*

Commercial

Group Policy

Health Maint. Org. (HMO)

Individual Policy

Indian Health Service

Long Term Policy

Litigation

Medicare Primary

Medicare Part B

Medicaid

Medigap Part B

None

Other Public Insurance

Other Private Insurance

Other

Personal payment (cash- no ins)

Supplemental Policy

VA insurance

Unknown

Not Collected
Health Insurance Type: Check One*

Aetna

AK Native Health Care

Blue Cross/Blue Shield

CIGNA

Client Self Pay

HMO

Indian Health Services

Medicaid

Medicare

No Charge

Not Collected

Other Government Grant

Other Native Health Care

Other Private

Other Public

Sliding Scale; client partial payment

Sliding Scale, No Charge

Unknown
Annual Household Income:*

Approximate or exact numeric amount, and include Alaska PFDs if applicable
Occupation (O-Net): Check One*

Accommodation & Food Services

Administrative & support Services

Agriculture, Forestry, Fishing, & Hunting

Arts, Entertainment, & Recreation

Construction

Educational Services

Finance & Insurance

Government

Health Care & Social Assistance

Information

Management of Companies & Enterprises

Manufacturing

Mining, Quarrying, Oil & Gas Extraction

Other Services (Except Public Admin.)

Professional, Scientific, & Technical Svcs.

Real Estate & Rental & Leasing

Retail Trade

Self-Employed

Transportation & Warehousing

Utilities

Wholesale Trade

None

Not Applicable

Life Domains/Financial/Household Information (Continued)

Living Situation: Check One*

Assisted Living Facility

Correction/Detention Facility

Crisis Residence

Foster Care

Group Home

Halfway House

Homeless

Hospital for Non-psychiatric purposes

Hospital for psychiatric purposes

Nursing home

Private Residence w/o supportive services

Private Residence with supportive services

Residential Treatment

Shelter

Therapeutic Foster Care

Transitional Housing

No Response

Other

Unknown
Marital Status: Check One*

Never Married-single

Married

Cohabitating

Separated

Divorced

Widowed

No Response

Not Collected

Unknown
Number of people living with client:*

Number of children in household:*

Number of children in residential setting:*

Number of children in residential setting receiving services:*

Number of children living with client*

Do You Currently Take Any Medications?*

Yes

No
If YES List All Medications
Name of Medication:*

Dosage*

Frequency:*

Name of Medication:

Dosage

Frequency:

Name of Medication:

Dosage*

Frequency:*

Name of Medication:

Dosage

Frequency:

Name of Medication:

Dosage

Frequency:

List All Allergies:

Life Domains/Substance Abuse Information

When you can have anything you want what is your FIRST drug of choice? (Select Only 1)*

Alcohol

Barbiturates

Benzodiazepines

Cannabis

Cocaine/Crack

Designer Drugs

Heroin

Inhalants

Marijuana/Hashish

Methamphetamines

Nicotine

Non-beverage alcohol

Non-prescription methadone

Other Amphetamines

Other Hallucinogens

Other Opiates/Hypnotics

Other Tranquilizers

Other Stimulants

Over the Counter Meds

Oxycodone

OxyContin

PCP

Steroids
Frequency of Use:*

More than 3 times daily

2-3 times daily

Daily

3-6 times per week
Method of Use:*
Inhalation
IV injection
Nasal
Non-IV Injection
Oral
Smoking
N/A
Unknown
Severity of Use:*

Use

Abuse

Dependence

Not Applicable
Think About Your FIRST Drug of Choice
Age of FIRST use?*

Number of days since LAST use?*

When you can have anything you want what is your SECOND drug of choice? (Select Only 1)*

Alcohol

Barbiturates

Benzodiazepines

Cannabis

Cocaine/Crack

Designer Drugs

Heroin

Inhalants

Marijuana/Hashish

Methamphetamines

Nicotine

Non-beverage alcohol

Non-prescription methadone

Other Amphetamines

Other Hallucinogens

Other Opiates/Hypnotics

Other Tranquilizers

Other Stimulants

Over the Counter Meds

Oxycodone

OxyContin

PCP

Steroids
Frequency of Use:*

More than 3 times daily

2-3 times daily

Daily

3-6 times per week
Method of Use:*
Inhalation
IV injection
Nasal
Non-IV Injection
Oral
Smoking
N/A
Unknown
Severity of Use:*

Use

Abuse

Dependence

Not Applicable
Think About Your SECOND Drug of Choice
Age of FIRST use?*

Number of days since LAST use?*

When you can have anything you want what is your THIRD drug of choice? (Select Only 1)*

Alcohol

Barbiturates

Benzodiazepines

Cannabis

Cocaine/Crack

Designer Drugs

Heroin

Inhalants

Marijuana/Hashish

Methamphetamines

Nicotine

Non-beverage alcohol

Non-prescription methadone

Other Amphetamines

Other Hallucinogens

Other Opiates/Hypnotics

Other Tranquilizers

Other Stimulants

Over the Counter Meds

Oxycodone

OxyContin

PCP

Steroids
Frequency of Use:*

More than 3 times daily

2-3 times daily

Daily

3-6 times per week
Method of Use:*
Inhalation
IV injection
Nasal
Non-IV Injection
Oral
Smoking
N/A
Unknown
Severity of Use:*

Use

Abuse

Dependence

Not Applicable
Think About Your THIRD Drug of Choice
Age of FIRST use?*

Number of days since LAST use?*

Number of Days Abstinent in the last 30 days (no use of alcohol, Marijuana, or illegal drugs*

Current Use of Tobacco: Check one*

Cigarettes

Cigars/Pipes

Combination

Smokeless Tobacco

Not Applicable/None

Life Domains/Legal Status

Number of Arrests in past 30 days:*

Legal Status at time of Admission:*

Court ordered for alcohol treatment

Court ordered for mental health treatment

Court order for observation and evaluation

Court ordered juveniles; DJJ custody

Court ordered juveniles; parents retain custody

Furlough/Rehabilitative Leave

Incarcerated

Probation/Parole

Informal Probation

Protective Custody

Office of Children’s Services Custody

Deferred Prosecution

Deferred Sentence

Community Sentencing

Emergency Commitment

Title 12 – Not guilty by reason of insanity

Case pending

30-day commitment

90-day commitment

180-day commitment

None/no involvement

Not Applicable
Anything else you would like to add at this time:
Once submitted your information will be forwarded to the True North Recovery Inc Team, who will contact you within 24hours. Feel free to drop in or call to schedule your enrollment.
CAPTCHA
Untitled

First Choice

Second Choice

Third Choice
Phone
This field is for validation purposes and should be left unchanged.