Opioid Health Home Referral Application
Date of Referral
*
-
Month
-
Day
Year
Date
Initial Appt. Date/Time
-
Month
-
Day
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
00
05
10
15
20
25
30
35
40
45
50
55
AM
PM
AM/PM Option
Referral Source
Email Address
example@example.com
Treatment request (please check):
*
Substance Use Therapy
Medication Assisted Treatment
Opioid Health Home
Comp Assessment
Family Recovery Skills Program
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Gender
Select
Male
Female
N/A
Are you currently taking medications?
*
Yes
No
If yes, current medications:
*
Current Provider:
*
Reason for requesting psychiatric medication management:
*
Ins./Medicare #
Ins./Mainecare #
Self Pay
Select
Yes
No
Current Vocational/Employment Status:
*
Clubhouse Transitional Employment
Competitively employed full-time (32 or more hours per week)
Competitively employed part-time (Less than 32 hours per week)
Not employed – looking for work
Not employed – not Looking for work
Self-employed
Stay-at-home parent of a child under the age of 18
Student
Volunteer on a regular basis (in the last 30 days)
Working with supports full-time (32 or more hours per week)
Working with supports part-time (Less than 32 hours per week)
Employer or Type of Work
Employer
Job Title
Marital Status
Married
Single
Separated
Widowed
Divorced
Cohabitating
Do you have your own transportation?
Select
Yes
No
Do you use a transportation service?
Select
Yes
No
Do you have case management services with another agency?
Select
Yes
No
If yes, with who?
Current Residence:
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
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
State
Zip Code
Phone Number
*
-
Area Code
Phone Number
History
Previous Treatment?
*
Select
Yes
No
Where?
When?
Type?
MAT Dr. (If Applicable
Where? (If Applicable)
Phone Number (If Applicable)
-
Area Code
Phone Number
Date of last visit (if Applicable)
/
Month
/
Day
Year
Date
Are you currently taking medications?
*
Yes
No
Reason for seeking treatment:
*
Please verify that you are human
*
Submit
Should be Empty: