HH New Patient Registration Form V2

New Patient Registration Form

Welcome to Hope and Healing Clinic. Please complete the secure form below to begin your registration. Once submitted, a member of our team will review your information and follow up with you within 1-2 business days. Your privacy is important to us. All information submitted through this form is HIPAA-compliant, securely transmitted, and kept confidential.
Are you submitting this registration form for yourself or someone else?
Relationship to Patient
Form Submitters Name

First NameLast Name
Form Submitter's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referring Organization Name
Referrer Name

First NameLast Name
Referrer's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Referrer's Email
Patient Name

First NameLast Name
Gender
Are you pregnant or have you delivered in the last 90 days?
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Date of Birth:
MM/DD/YYYY
Last four of SSN
Address (optional)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Eligibility Questions
Do you use any opioids or opiates such as Heroine, Oxycodone or Fentanyl?
Why are you seeking treatment?
Currently Receiving Services Elsewhere?

If you are currently a patient at another OTP (methadone program or Suboxone provider) please complete a Release of Information before your intake.

This allows Hope and Healing Clinic to communicate with your current provider, verify treatment information, coordinate care, and help prevent delays.

Complete Release of Information Form: [Insert ROI Link Here]
Are you currently a patient of another OTP clinic?
What is the name of the current clinic?
What medication are you dosing with?
What was your most recent dose amount (mg)?
When was your most recent dose?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Transportation Information
We’re here to help! Transportation assistance is available to help make getting to and from the clinic easier, and we would love to help you take advantage of this service. ADA accommodations are also available upon request to help ensure your transportation and clinic experience meet your needs. Please speak with a member of our team so we can help arrange the support that works best for you.
Do you have transportation for your appointment?
What to Expect at Your Intake Appointment

At your intake appointment, Hope and Healing Clinic will complete several required intake steps.

Please plan to spend at least 90 minutes at the clinic for your intake appointment. The appointment may take longer depending on your needs.
Should be Empty:

New Patient Registration Form

Eligibility Questions