YourPath Care, PLLC Intake
We have tried to make this as painless as possible. There is a lot of information that we need you understand and agree with to safely and legally get you connected to services, including Suboxone or an assessment. This should take about five minutes. If you have any questions, please let us know. We are so glad you're here!
Organization
Please write the organization who referred you to YourPath
Type of care I am seeking (select all that apply):
Addiction Medicine (Suboxone, etc.)
Psychiatry and Mental Health
Preferred virtual appointment date (not guaranteed, but we will do our best)
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Month
-
Day
Year
Date
Preferred virtual appointment time
Morning
Afternoon
No preference
Client Name
*
First Name
Last Name
Date of Birth:
*
-
Month
-
Day
Year
Date
Client Phone Number
*
Please enter a valid phone number.
It's ok to text me at this number
*
Yes
No
Client Email
example@example.com
Address (if you don't have a permanent address, just put in what city you are located in most often)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your gender?
*
Male
Female
Transgender
Two-Spirit
Non-binary
Prefer to self-describe
Last four digits of your social security number:
* We need this to comply with a Minnesota requirement. If you would prefer to give us this information in another way, let us know.
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By signing and checking the previous boxes, I consent to all terms and conditions.
*
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Insurance Information
We will need your insurance information before we are able to start services. If you have your card handy, please attach pictures of it below. If you don't, we at least need the ID numbers before we can schedule you.
Insurance card: Front
Insurance card: Back
Insurance Provider (leave blank if unsure):
Insurance ID Number
Insurance PMI Number
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AUDIT-C
Date of Screening
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Month
-
Day
Year
Date
Within the past year, how often did you have a drink of alcohol?
Never
Monthly (e.g. Special occasions/rare)
2-4 times a month (e.g. 1x on the weekend - "Friday's only" or "every other Thursday"
2-3 times a week (e.g. weekends - Friday-Saturday or Saturday-Sunday)
4 or more times per week (e.g. daily or most days/week)
Within the past year, how many standard drinks containing alcohol did you have on a typical day?
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
Within the past year, how often did you have six or more drinks on one occasion?
Never
Less than monthly
Monthly
Weekly
Daily or almost daily
AUDIT-C Total
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DAST
Using drugs can affect your health and some medications you may take. Please help us provide you with the best medical care by answering the questions below.
Date of Screener
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Month
-
Day
Year
Date
Drug(s) if choice
Methamphetamine (speed, crystal)
Cannabis (marijuana, pot)
Inhalants (paint thinner, aerosol, glue, etc.)
Tranquilizers (valium)
Cocaine
Narcotics (heroin, oxycodone, methadone, etc.)
Hallucinogens (LSD, mushrooms)
Other
How often have you used these drugs?
Monthly or less
Weekly
Daily or almost daily
1. Have you used drugs other than those required for medical reasons?
No
Yes
2. Do you abuse more than one drug at a time?
No
Yes
3. Are you always able to stop using drugs when you want to?
No
Yes
4. Have you ever had blackouts or flashbacks as a result of drug use?
No
Yes
5. Do you ever feel bad or guilty about your drug use?
No
Yes
6. Does your spouse (or parents) ever complain about your involvement with drugs?
No
Yes
7. Have you neglected your family because of your use of drugs?
No
Yes
8. Have you engaged in illegal activities in order to obtain drugs?
No
Yes
9. Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs?
No
Yes
10. Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)?
No
Yes
Have you ever injected drugs?
Never
Yes, in the past 90 days
No, more than 90 days ago
Have you ever been in treatment for substance abuse?
Never
Currently
In the past
DAST Total
Submit
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