Request an Appointment (SECURED)
Genesis Treatment Services Home Genesis Treatment Service's Client Resources About Genesis Treatment Services Drug facts about opiate and heroin addiction Frequently Asked Addiction Questions How to contact Genesis Treatment Services

Genesis Treatment: "Intake Form"
Date of initial contact: (ie. 08/17/09)
*Check one:
Street Address:
Zip Code:
*Date of Birth: (ie. 08/17/09)
Preferred method of contact:
*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