Emergency Contacts (List two)
Please provide insurance information below for purpose of coordinating clinical services.
Substance Use History Form
Cocaine (including Crack)
Methamphetamines (crystal meth)
Amphetamines/Other Stimulants: Ritalin, Adderall, Dexedrine, uppers etc.
Benzodiazepines/ Tranquilizers: Xanax, Valium, Librium, Ativan etc.
Sedatives/Barbituates: Phenobarbital, Amytal, Seconal etc.
Street or Illicit Methadone/Suboxone
Other Opioids: Percocet, Oxycontin, Vicodin, Dilaudid, Morphine, Demerol, Tylenol 3 etc.
Hallucinogens: LSD, PCP, mushrooms, ketamine, MDMA (ecstasy) etc.
Inhalants: glue, whippets, aerosols etc.
Synthetic Cannabinoids: K2/Spice
Synthetic Cathinones: Bath salts, Flakka etc.
New Psychoactive Substances: Kratom
Illegal Use of Prescription Drugs: Gabapentin, Ambien etc.
Authorization for Release of Information
I hereby request and authorize:
The Recovery Connection LLC
2832 Saratoga Drive
Winchester, VA 22601
Phone: (540) 504-7671/Fax: (540) 504-7818
To disclose or obtain information (either written or verbal) from:
All information I hereby authorize to be obtained from this agency will be held strictly confidential and cannot be released by the recipient without my written consent. I understand that this authorization will remain in effect for:
I understand that unless otherwise limited by state or federal regulation, and except to the extent that action has been taken which was based on my consent, I may withdraw this consent at any time.