Starting Treatment: Intake Form

Ready to Start Treatment?

Fill out Reach for Recovery’s intake form if you are ready to start treatment. You will receive a follow up call the following business day to review any additional details and schedule your first appointment.

First and Last Name*

Today's Date*

Date of Birth*

Age

Phone Number*

Address

State

Zip Code

Are you experiencing homelessness?

County of Residence

Client Gender

Do you identify as part of the LGBTQ+ Community?

What is your highest level of education completed?

Are you a veteran?

What is your marital status?

Emergency Contact Name*

Emergency Contact Relationship

Emergency Contact Phone*

What is your reason for entering treatment?*

Primary Care Doctor

Phone Number

Would you like for Reach for Recovery to coordinate care with your primary care doctor?

If You Are Seeking Substance Use Treatment

What is your primary substance of abuse?

Are you using drugs through injection?

Are you pregnant or parenting?

How many dependents do you have?

Is CPS involved?

Have you been in treatment before?

When was the last time that you used?

What is your frequency of use?

Do you have any legal involvement?

Name of parole or probation officer

Email of parole or probation officer

If You Are Seeking Mental Health Treatment

Have you been in treatment before?

What is your reason for seeking treatment?

What mental health medications are you taking (if any)?

Medicaid

Medicaid Number

Medicaid Plan

If Medicaid not active, have you applied?

If yes, date applied

Health Insurance

Insurance Provider

Policy Number

No Insurance

Insurance Status

Are you employed?

What type of work do you do?

Employer Name

I want to get help

I want to support

I want to learn more

Holland (Main Office)

483 Century Lane
Holland, MI 49423

Grand Haven

700 Washington Ave., Suite 220
Grand Haven, MI 49417

both Reach out-patient locations are handicap accessible.

request an appointment

(616) 396-5284

walk-in hours daily from 8am – 4pm

a 501(c)3 addiction recovery nonprofit