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

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  • Personal Health History

  • Drug(s) of choice and usage history

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  • Alcohol/Drug Treatment History

    Please list last two treatment
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  • Mothers Only

    PPW Treatment-Pregnant Woman and Woman with Children
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  • 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:

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  • Trauma Evaluation


  • Disability and Payment

    Payment Options will be discussed during the intake process
  • Referral Source and Additional Information

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  • Should be Empty:
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