Start Your Rule 25 Assessment Here
Do you have Health Care Insurance? Provider: (choose one)
MEDICABC/BSPREF ONEHP UCAREMEDICA MHPHennepin HealthCCDTF/MA
Who referred you to us?
PO/Parole Officer
Courts
Family/Friend
Another TX Center
Other
Self Referral
If treatment is recommended is there a provider you would prefer?
Evening or Weekend?
Have you had a assessment or Rule 25 in the past 45 days? YesNo
Is someone requiring you to receive a rule 25 assessment? YesNo
What is your drug of choice?
Date of Most Recent Use
Amount
