- REFERRAL SOURCE
- SOCIAL HISTORY
- Present/past alcohol/drug/pyschiatric
treatment or hospitalization in past 5 years:
- How many days?
- Did you complete?
- ALCOHOL/DRUG USE
- Date last used
- How much on that date?
- Average Frequency/ Average Amount
- HEALTH INSURANCE INFORMATION (Patient is the Scubscriber)
- PATIENT HEALTH INSURANCE
- IF APPLICABLE, SECONDARY INSURANCE -
- OTHER HEALTH INSURANCE
This field is for validation purposes and should be left unchanged.