Cornerstone Pre-Cert Form

1
Full Name* This field is required
First Name
Last Name
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2
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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3
Contact Phone Number* This field is required
Area Code
Phone Number
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4
Insurance Company Name
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5
Policy ID & Group NumberLocated on the insurance card
Policy ID Number
Group ID Number
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6
Name of Policy Holder
Name
Relationship to Patient
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7
Policy Holder's Employer
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8
Policy Holder's Date of Birth
Date
Year
Month
Day
Date
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9
Policy Holder's Social Security Number
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10
Insurance Company Benefits Phone NumberUsually on the back of insurance card. (Behavioral Health/MH/SA)
Area Code
Phone Number
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11
Why is the potential patient seeking treatment now? Was there a precipitating event? If so, when?
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Ok
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12
Drug Use History (First Substance Is Drug of Choice)
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13
If last use was more than 3-5 days ago, please explain why
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Ok
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14
Has potential patient attempted to decrease use?
YESNO
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15
Has the potential patient ever used substances intravenously?
YESNO
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16
Has the potential patient ever reported binge use?
YESNO
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17
Are you currently impaired?If you are potential patient
YESNO
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18
Experiencing Sweat or Chills?
Yes or No
Last time experienced or frequency
Please provide any specific details
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19
Experiencing Nausea?
Yes or No?
Last time experienced or frequency
Please provide any specific details
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20
Experiencing Vomiting?
Yes or No
Last time experienced or frequency
Please provide any specific details
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21
Experiencing Tremors?
Yes or No
Last time experienced or frequency
Please provide any specific details
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22
Experiencing Insomnia?
Yes or No
Last time experienced or frequency
Please provide any specific details
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23
Experiencing Irritability?
Yes or No
Last time experienced or frequency
Please provide any specific details
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24
Experiencing Body Cramps?
Yes or No
Last time experienced or frequency
Please provide any specific details
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25
Experiencing Dizziness?
Yes or No
Last time experienced or frequency
Please provide any specific details
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26
Please indicate if potential patient has been diagnosed with any of the following:
Epilepsy
Hypertension
Pancreatitis
Cardiac Problems
Cirrhosis
Diabetes
Gastric Bypass
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27
If you answered yes to any of the previous conditions please provide the date, physician and list any medications the potential patient is currently taking.
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Ok
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28
Does the potential patient have a Primary Care Physician?
Yes or No
Last Visit?
Any future appointments?
If potential patient has any other healthcare providers please list them here.
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29
Please list any current prescriptions the potential patient is taking:Please include name , dosage, reason for taking and any complaints they have about it
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Ok
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30
Has potential patient experienced any increase or decrease in appetite along with weight gain or loss?If yes please explain or simply type no
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31
Has the potential patient experienced any unexplained injuries?If yes please explain or simply type no
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32
Is the potential patient pregnant or suspect pregnancy?
YESNO
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33
Can the potential patient perform daily living activities unassisted?(Bathing, Feeding, Dressing Themselves)
YESNO
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34
Does the potential patient have any current medical or physical complaints?
Yes or No?
If yes please explain
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35
Please list any recent surgeries and approximate date
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Ok
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36
Does the potential patient have any mental health diagnosis?
Anxiety
Depression
Bipolar
Schizophrenia
ADD/ADHD
Other
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37
If you answered yes on the previous question, please list the date of diagnosis, the physician, and any medications.
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Ok
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38
Is potential patient under the care of a mental health provider?
Yes or No
If yes when was last visit?
Frequency of visits?
Reason for seeing?
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39
Please select any that the potential patient has experienced
Blackouts
Guilt
Passing Out
Hopelessness
Helplessness
Memory Loss
Shame
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40
If you checked any of the previous questions, were the symptoms present while under the influence or while in withdrawal?
Under the influence
While in withdrawal
Both
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41
Has the potential patient ever had an overdose?
Yes or No
Was it on purpose?
What substance was used?
Did the potential patient seek medical attention?
Please provide specific details
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42
Does potential patient currently have suicidal thoughts?
YESNO
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43
Is there any history of suicidal thoughts or attempts?
Yes or No
With or without a plan?
If Yes, Please provide specific details
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44
Does the potential patient currently have homicidal thoughts?
YESNO
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45
Is there a history of homicidal thoughts or attempts?
Yes or No
With or without a plan?
If Yes, Please provide specific details and detail to whom
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46
Has potential patient been diagnosed or shown signs of an eating disorder?
Yes or No
If yes, please explain
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47
Does the potential patient have any history of self-mutilation?
Yes or No
If yes, please explain
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48
Is the potential patient currently experiencing hallucinations?
Yes or No?
If yes, please explain
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49
Has the potential patient ever had hallucinations?
Yes or No
If yes please explain. Were they auditory, visual, commands?
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50
Which of the following apply to the potential patient
Married
Single
Separated
Divorced
Widowed
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51
Does potential patient have children?
Yes or No
If yes, what are their ages?
Are they currently living in home with potential patient?
If they are not currently living with potential patient , please explain why
If they are living with potential patient, does their substance use affect ability to take care of family? Please explain
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52
Is there any involvement from a state agency regarding their children?
Yes or No
If yes, please explain
Agency / Case worker name
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53
Does spouse or anyone the potential patient lives with use?
YESNO
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54
Does potential patient's family or friends use?
YESNO
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55
How many friends and family use?
None
Some
All
Family members
Friends
Family members
Friends
None
Some
All
None
Some
All
1 of 2
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56
Does potential patient have a sober support system?
Yes or No
If yes, please explain
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57
Has spouse or significant other threatened to leave?
Yes or No
If yes, please explain
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58
How has potential patient's use affected relationships with friends, family and spouse?Please give details
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Ok
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59
Does the potential patient feel they can manipulate their friends/family to hide or accommodate using?
Yes or No
If yes, please explain
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60
Did the potential patient graduate high school?
Yes or No
If no, was drug or alcohol use a factor?
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61
Did potential patient attend college?
Yes or No
Did they graduate?
What degree did they get?
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62
If potential patient didn't complete school, was drug use a factor?Please explain
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Ok
Ok
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63
Is the potential patient currently employed?
Yes or No
Employer Name
Did employer refer potential patient to Cornerstone?
Does potential patient have an EAP?
If yes to EAP, please provide name and phone number
How long has potential patient been with employer?
Has the potential patient been reprimanded at work? If yes please explain.
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64
Has potential patient experienced any of the following at work?Check all that apply
Frequent Absences
No Call / No Show
Frequent Tardiness
Using At Work
Use Before Work
Terminations
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65
How much does potential patient spend on alcohol/drugs per week?
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66
Is the potential patient currently behind on financial obligations?
Yes or No
If yes please explain
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67
Has the potential patient experienced any of the following: pawning, stealing, dealing to support their use?
Yes or No
If yes, please explain
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Should be Empty: