Client Full Name*
Today's Date
Client Date of Birth*
Client Gender
Choose one
Female
Male
Non-binary
Other
Prefer not to say
Client Email
Client Phone Number
Client Address
State
Zip Code
Client County of Residence
Choose a County
Allegan
Ottawa
Kent
Muskegon
Mason
Newaygo
Seeking Services at:*
Choose an option
Chester A. Ray (men's treatment center)
Harbor House (women's treatment center)
Emergency Contact Name*
Emergency Contact Phone*
Special Needs or Considerations (e.g., dietary restrictions, accessibility requirements)
Name of Agency/Person
Contact Person's Name*
Contact Person's Email*
Contact Person's Phone
Primary Substance of Abuse
Choose an item
Alcohol
Cocaine
Heroin
Methamphetamine
Marijuana
Other Opiates (fentanyl, prescription drugs)
Other
Current Frequency and Amount of Use
Duration of Substance Use
Is the person using the substance through injection?
Choose "yes" or "no"
Yes
No
History of Previous Treatment (if any)
Current Medications (if any)
Current Medical Provider
Current Medical Conditions
Mental Health History (if relevant)
ASAM-C Assessment (if available)
Please attach ASAM-C Summary and Narrative reports or include relevant
dimensions assessed (e.g., Acute Intoxication/Withdrawal Potential, Biomedical
Conditions and Complications, etc.)
Legal Information
Legal Issues or Involvement
Probation or Parole Status
Choose an option
Probation
Parole
Not applicable
Expected Court Appointments
Child Welfare Services Involvement
Are Child Welfare Services (CPS, Foster Care) Involved?
Choose "yes" or "no"
Yes
No
(If Yes) Description of involvement
(If Yes) Expected Court Appointments
Medicaid
Medicaid Number
Medicaid Plan
If Medicaid not active, have you applied?
Choose "yes" or "no"
Yes
No
If yes, date applied
Health Insurance
Insurance Provider
Policy Number
Please attach additional documentation that will support the referral if you have it
Verification of authorization for 3.5 Residential Treatment level of care. (ASAM-C Assessment reports)
Verification of authorization for funding through Medicaid or Private Insurance.
Current medication list
If relevant, psychiatric evaluations, medical records, legal documents.
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