Clone of New Patient Registration Form

Patient Name* This field is required.

First Name

Middle Name

Last Name

Street Address* This field is required.

Address Line 1

City* This field is required.

State* This field is required.

Zip Code* This field is required.

County of Residence * This field is required.

Date of Birth* This field is required.

Social Security Number* This field is required.

Contact Number* This field is required.

Area Code

Phone Number

E-mail* This field is required.

Name of Insurance Company* This field is required.

Drivers License (Front)* This field is required.Or Other Form of Photo ID or Picture of Self

Drivers License (Back)* This field is required.Or Other Form of Photo ID

Sex* This field is required.

Male

Female

Refused

Military Status* This field is required.

Marital Status* This field is required.

Primary Source of Income* This field is required.

Sexual Orientation* This field is required.

Straight/Heterosexual

Gay/Lesbian

Bisexual

Other

Refused

Ethnicity* This field is required.

Puerto Rican

Mexican

Cuban

Other Hispanic or Latino

Not of Hispanic or Latino origin

Hispanic or Latino-Specific Origin no specified

Refused

Race* This field is required.

White

Black or African American

Asian

American Indian or Alaskan Native

Native Hawaiian or other Pacific Islander

Another Race

Refused

Referral Source* This field is required.

Refused

Individual/Self

Alcohol/Drug Use Care Provider

Other Health Care Provider

School (Educational)

Employer/Employee Assistance Program (EAP)

Other Community Referral

State/Federal Court

Other Court

Probation/Parole

Other Recognized Legal Entity

Diversionary Program

Prison

OWI/DUI

Other Criminal Justice Referral

Unknown Criminal Justice

Name of Individual or Practice you were referred by* This field is required.Please use n/a if not applicable

First/Last Name of Probation/Parole Officer or other Referral Source (e.g. Attorney)* This field is required.

Email of Referral Source for reporting purposesif known, see above

example@example.com

Phone Number of Referral Source for reporting purposesif known, see above

Area Code

Phone Number

Arrests in the past 30 days* This field is required.

Yes

Refused

Type option 4

Arrests Related to Substance Use in Past 30 DaysRequired if above is yes (e.g. OWI/Possession/Public Intoxication, etc.)

YES

Refused

Arrests in the past 12 months* This field is required.

Yes

Refused

If yes, how many times?required if above response is yes

How many arrests PRIOR TO THE LAST 12 MONTHS* This field is required.

4 or more

Refused

Occupation * This field is required.

Do you feel safe at home?* This field is required.

Yes

Please ask me more about this

Are you currently pregnant?* This field is required.

YESNO

Health Insurance* This field is required.

Private Insurance

Blue Cross/Blue Shield

Medicare

Medicaid (Amerigroup/Total Care)

HMO

Other

None

Refused

Living Arrangement* This field is required.

Education Grade Level* This field is required.

Employment Status* This field is required.

Refused

Full Time

Part Time

Unemployed

Not In Labor Force- Homemaker

Not In Labor Force- Student

Not In Labor Force- Retired

Not In Labor Force- Disabled

Homeless

Not In Labor Force- Other

Education Grade Level (Highest Completed)* This field is required.

Refused

Less than one grade or no schooling

10-11

12 or GED

Vocational School

Self-contained special education

1st year college

2nd year college

3rd year college

4th year college

Some post-graduate study

Masters Degree Completed

Post-graduate study 19-25 years

What are we seeing you for?* This field is required.Please let us know why you are needing services?

How would you rate your quality of life?* This field is required.

Very Dissatisfied

Dissatisfied