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Personal Information

Gender
May we leave Voicemail?
Do you have a vehicle?
Do you have a valid driver's license?

Recovery Information

Currently/recently in treatment
Did you complete program?
Have you lived in recovery housing before?

Emergency Contacts (List two)

Employment/Education Information

Are you employed?
Are you enrolled in school or job training program?

Legal Information

Are you on probation/parole?
Have you ever been convicted of any violent or sexual crimes?

Medical History/Medications

Hospitalizations in past 12 months?

Please provide insurance information below for purpose of coordinating clinical services.

Do you have dual coverage?

Substance Use History Form

Alcohol

Marijuana

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.

Heroin

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:

The following type(s) of information from my records (and any specific portion thereof):

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:

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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.