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New Patient Intake Form
First Name
Gender
Male
Female
Marital Status
Married
Divorced
Separated
Single
Other
City
Zip Code
County
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Phone Number
Insurance Provider
Medicaid
None
Private Insurance
Self-Pay
Eduction
Grade 12 or GED
College
4 Year University
Trade School
Other
Allergies
Yes
No
Background Information
Drug of Choice (First Preference)
Alcohol
Heroin
Prescription Narcotics
Cocaine
Crack Cocaine
Benzodiazepines
Marijuana
Amphetamines
Other
Age of First Use
Date of Last Use
Number of Prior Treatments
Have you had any legal issues?
Yes
No
Notes/Comments
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