Comprehensive Assessment Screening Form

Fields marked with * are required.

Client Information

First Name*

Last Name*

Date of Birth

Street Address*

City*

State*

ZIP*

Phone Number*

Alternate Phone

Email Address*

Reason for calling today*

Insurance

Health Care Insurance Provider

PMI #

Medical ID #

Group #

Treatment Preferences

Preferred provider if treatment is recommended

Evening or Weekend availability?

EveningWeekendBothNeither

Assessment

Consequences of alcohol/drug use

Have you had an assessment or Rule 25 in the past 45 days?*

YesNo

Is someone requiring you to receive a Rule 25 assessment?*

YesNo

Drug of choice

Date of most recent use

Amount

Consent & Authorization

By submitting this form, I authorize Alliance Wellness Center to use the information provided to assess my treatment needs and contact me regarding services. All information is kept strictly confidential in accordance with applicable state and federal laws, including 42 CFR Part 2 and HIPAA.

Submission of this form does not constitute enrollment in a treatment program. A full clinical assessment will be conducted prior to any treatment recommendation.

Full Name (electronic signature)*

Today's Date*

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Call us at 952-562-3740. Our team is available Monday–Friday, 8 AM–4 PM.

Client Information

Insurance

Referral

Treatment Preferences

Assessment

Consent & Authorization