R.E.A.C.H. Recovery Counseling New Client Intake Form

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R.E.A.C.H. RECOVERY
NEW CLIENT INTAKE FORM

Please fill out the intake form below. Upon submitting this form you will be contacted by R.E.A.C.H. to schedule your first appointment. Thank you for choosing R.E.A.C.H. Restoration Counseling.

R.E.A.C.H. New Client Recovery Intake form.

* Indicates required field

Name *

First

Last

Date of birth *

Email *

Phone Number *

If client is under 18yrs, Parent/Caregiver Name *

Clients age? *

Less than 13 13-18 19-25 26-35 Over 36 Prefer not to say

Address *

Line 1

Line 2

City

State

Zip Code

Country

Gender Identity *

Sexual Orientation *

If Other please specify: *

Substance Abuse Recovery Counseling (can select multiple options) *

Intensive Outpatient SUD Counseling (admission into the IOP supportive housing and recovery services) Out Patient SUD Counseling (recovery services not needing supportive housing) Medical Assisted Treatment SUD Unsure would like more information

How would you prefer to receive services *

Face to Face (in person) Telehealth (over the phone or computer) No preference

Which County are you requesting services? *

If you are requesting R.E.A.C.H. Recovery do you need supportive housing? *

Brief Summary of Presenting Issue/s: (Please include current diagnoses and medications, if known) *

NAME OF YOUR HEALTH INSURANCE COVERAGE (PUT NONE IF NOT INSURED) *

Insurance Member ID *

Would like assistance in exploring possible insurance options? *

WOULD YOU BE SELF PAYING DUE TO NOT HAVING INSURANCE? *

Yes No

How did you hear about this site? *

Internet Search Advertisement Friend Social Media Other

Were you referred to REACH? If Yes then by who? *

Have you used any non prescribed prescription or non prescription drugs or alcohol within the past 30 days? *

Yes No

What is the date of your last substance use? *

What substance/s did you use? *

Upon submitting this form you will be emailed or texted a link for the Intake and Screenings needed. Please complete and sign these forms. Services will not be able to start unless they are completed and signed.
Thank you for choosing R.E.A.C.H. Counseling!

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