HH Online Referral Form NEW

Harbor House Chemical Dependency Services Referral Form All questions contained in the questionnaire are strictly confidential and will become part of your medical record.
Date

Month Day Year
Date
Name *
Date of Birth

Month Day Year
Harbor House can only admit patients that are 18 or older.
Age
Sex
Gender Choice
Home/Business Phone

Area Code Phone Number
Cell Phone

Area Code Phone Number
Email
example@example.com
Personal Health History
List current physical problems
List current mental health problems
Have you been hospitalized in the past 30 days?
If yes, explain
Drug(s) of choice and usage history
1st Drug of Choice:
Age of first use
Date of last use

Month Day Year
Date
How much/often?
Method of use:
Please list oral, iv, snorting, smoking or other
2nd Drug of Choice:
Age of first use
Date of last use

Month Day Year
Date
How much/often?
Method of use:
Please list oral, iv, snorting, smoking or other
Alcohol/Drug Treatment History

Please list last two treatment
Date of 1st Treatment

Month Day Year
Date
Facility:
Type of treatment residential, outpatient, etc
Did you complete the treatment
Date of 2nd Treatment

Month Day Year
Date
Facility:
Type of treatment residential, outpatient, etc
Did you complete the treatment
Total number of Treatment Programs
List any current legal issues( Pending Cases and then below indicate if you are in a drug court or on probation/parole
Are you in Drug Court
Name of Drug Court
Are you on Probation or Parole
Name of Probation or Parole officer
Mothers Only

PPW Treatment-Pregnant Woman and Woman with Children
Do you want to enter PPW Treatment
Are you Pregnant
How many months
Do you want to bring your child-Please enter age
Name of CPS Worker
County of CPS Worker
CPS Phone Number

Area Code Phone Number
CPS Email
example@example.com
Medical Assisted Treatment Option
Do you have an Opioid addiction and want to be evaluated for Medically Assisted Treatment
Have you ever participated in a Medically Assisted Treatment Program
Are you currently enrolled in a Medically Assisted Treatment Program
Medical Questionnaire
Please check any of the following symptoms which you are currently experiencing

Depression Suicidal Thoughts Sexual Dysfunction Sleep Problems Gambling Obsessive thoughts Anxiety Eating Disorder Compulsive behavior Work problems Panic attacks Mood Swings Family problems School problems Mood swings Poor concentration Marital problems Financial problems Negative Thoughts Traumatic Stress Voices/Visions Substance Abuse Poor Memory Sleep Problems Anger Outburst
Please check any Medical and Mental Health Condition which apply to you and list any medication you have been prescribed for the conditions you have checked:
CONDITION (check if applicable to you)

Depression
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Bipolar Disorder
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Anxiety Disorder
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Obsessive Compulsive Disorder
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Schizophrenia or Paranoia
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Attention Deficit Disorder
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Autism Spectrum Disorder
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Suicidal thoughts/attempts
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Alcohol/Drug Abuse
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Eating Disorder
MEDICATION (if applicable)
CONDITION (check if applicable to you)

Obsessive Compulsive Disorder
MEDICATION (if applicable)
Epilepsy/Seizure Disorder

Epilepsy/Seizure Disorder
MEDICATION (if applicable)
Migraines

Migraines
MEDICATION (if applicable)
Lupus

Lupus
MEDICATION (if applicable)
Arthritis

Arthritis
MEDICATION (if applicable)
High Blood Pressure

High Blood Pressure
MEDICATION (if applicable)
Heart Attack

Heart Attack
MEDICATION (if applicable)
Stroke

Stroke
MEDICATION (if applicable)
Cancer

Cancer
MEDICATION (if applicable)
Diabetes

Diabetes
MEDICATION (if applicable)
Hepatitis

Hepatitis
MEDICATION (if applicable)
Sexually Transmitted Disease

Sexually Transmitted Disease
MEDICATION (if applicable)
Other 1 (please specify) and list Medication:
Other 2 (please specify) and list Medication:
Are you currently under the care of a mental health professional (psychiatrist, psychologist, licensed counselor ?
If yes, who are you currently seeing and why ?:
Have you ever attempted suicide ?
If yes, When ?

Month Day Year
Date
Trauma Evaluation
Have you ever experienced Psychological Trauma
Type of Psychological Trauma-Check multiple boxes if needed

Sexual Abuse Physical Abuse Terrorism Crime Victim Natural Disaster Witness to violence Witness to death Military Combat Accident Sex Trafficking Organized Crime/Gang
If yes, please list any details you would like to share?
Disability and Payment

Payment Options will be discussed during the intake process
Are you on disability ?
How do you plan to pay for treatment ?
Referral Source and Additional Information
How did you hear about Harbor House

Prior Patients Professional Referral Website Emails Facebook Other Social Media Family
Did anybody refer your to Harbor House?
Is there any additional information you wish to provide which may help us serve you better ?

Rate your experience with this referral form ?

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1 is Worst, 5 is Best

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Personal Health History

Drug(s) of choice and usage history

Alcohol/Drug Treatment History

Mothers Only

Medical Assisted Treatment Option

Medical Questionnaire

Please check any Medical and Mental Health Condition which apply to you and list any medication you have been prescribed for the conditions you have checked:

Trauma Evaluation

Disability and Payment

Referral Source and Additional Information