Opioid Health Home Referral Application

Opioid Health Home Referral Application
Date of Referral *

Month Day Year
Date
Initial Appt. Date/Time *

Month Day Year
Date AM/PM Option
Referral Source
Email Address
example@example.com
Treatment request (please check): *

Substance Use Therapy Medication Assisted Treatment Opioid Health Home
Name *

First Name Last Name
Date of Birth *

Month Day Year
Gender
Ins./Medicare #
Ins./Mainecare #
Self Pay
Employer
Job Title
Marital Status

Married Single Separated Widowed Divorced Cohabitating
Do you have your own transportation?
Do you use a transportation service?
Do you have case management services with another agency?
If yes, with who?
Current Residence:
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
History
Previous Treatment? *
Where?
When?
Type?
MAT Dr. (If Applicable
Where? (If Applicable)
Phone Number (If Applicable)

Area Code Phone Number
Date of last visit (if Applicable)

Month Day Year
Date
Are you currently taking medications? *

Yes No
Reason for seeking treatment:
Please verify that you are human *
Should be Empty: