Address: 3242 E. Main St. 2nd Floor, Columbus, OH, 43213
Email: info@icareohio.com
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Name:
County of Residence:
Date of Birth:
Phone Number:
Pregnant?
Yes
No
Number of weeks:
Prior CD treatment?
Yes
No
Readmit?
Yes
No
Reason for prior discharge:
Transfer from
Funding for treatment:
Drugs Of Choice
Primary :
Secondary :
Length of dependence on opiates:
Amount of use daily:
Symptoms of withdrawal:
Length of time after use before withdrawal starts:
Route of use:
Date and Time of last use:
Have you tried to stop using before and results:
Do you have any immediate health/physical needs?
Yes
No
Do you have a current mental health diagnosis?
Yes
No
Any current medications you are taking?
Risk for suicide?
Yes
No
Risk of Harm to others?
Yes
No
Stable Living Environment?
Yes
No
Sober support?
Yes
No
How did you hear about us?
Personal
Media
Agency
Funding Source
