Request an Appointment (SECURED)
 
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Genesis Treatment: "Intake Form"
 
Date of initial contact: (ie. 08/17/09)
 
*Check one:
 
*Name:  
 
SS#
 
Street Address:
 
State:
 
Zip Code:
 
*County:
 
*Date of Birth: (ie. 08/17/09)
 
*Phone#:
 
Email:
 
Preferred method of contact:
 
Age:
 
Gender:
 
*How did you hear about us? (Newspaper Ad, Client referral, etc...)
 
*How long have you been physiologically dependent on opiates? months years *(Both must be filled in)
 
How much do you use per day? mgs.
 
Route of use?
 
What other drugs do you use?
 
*Are you currently taking any Benzo's, Valium, Xanax, Klonipins)?
 
Prior treatment attempts:
 
*Have you been on a Methadone Maintenance program in the past?
 
*Are you currently on a Methadone Maintenance program?
 
If yes, where?
 
Current Dose: mg
 
Are you currently being treated for any medical conditions?
 
POC & Phone2:
 
Do you have transportation to the clinic?
 
*Payment Method: SelfPay | MA | If MA: # | MCO
 
SelfPay w/Private Ins. Name of Insurance Co.
 
Appointment Date: Time: Attended: (For Office Use Only)
 
Appointment Date: Time: Attended: (For Office Use Only)
 
 
 

Genesis Treatment Services - 1106 Business Parkway South, Suite B - Westminster, MD 21157
Phone: (410) 751-7771 - Fax: (410) 751-7736 - After Hours Hotline: (410) 979-0488