Access Center Pre-Registration

First Name

Last Name

Date of Birth

Preferred Phone Number

Email

Race/Ethnicity Hispanic Caucasian Black Asian Native American

Preferred Language

Insurance Provider

Do any of the following apply to you? Intravenous Drug User (IVDU) Pregnant Veteran Recent Overdose

If Pregnant...

Please answer the following.

How far along is the pregnancy?

Are you receiving prenatal care?

Name of OB/GYN

Phone Number for OB/GYN

Referral Details

Type of Referral

Referral Source

Drug and Alcohol Questions

Why do you want Drug and Alcohol Treatment?

What drugs and/or alcohol are you currently using?

Have you had Drug and Alcohol Treatment previously? Detox Inpatient Intensive Outpatient (IOP) Outpatient (OP) Methadone Suboxone No, I have not had drug and alcohol treatment.

Have you had mental health treatment previously?

Are you currently taking prescribed medications?

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