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SECTION 1: REFERRAL SOURCE INFORMATION

Referral Type (Select One):
Self-Referral
Parent/Guardian
Hospital
Physician
Therapist/Counselor
School
Court/Legal System
Other

SECTION 2: CLIENT INFORMATION

Birthday
Month
Day
Year

SECTION 3: EMERGENCY CONTACT


SECTION 4: INSURANCE INFORMATION

SECTION 5: CLINICAL INFORMATION

Primary Substance(s) Used (Check all that apply):
Frequency of Use:
Co-Occurring Mental Health Concerns (Check all that apply):

SECTION 6: RISK ASSESSMENT

History of Overdose:
Yes
No
Suicidal Ideation:
Yes (Current)
Yes (Past)
No
Homicidal Ideation:
Yes
No

SECTION 7: LEVEL OF CARE REQUESTED

Requested Services (Check all that apply):

SECTION 8: AVAILABILITY & ADMISSION

Transportation Needed:
Yes
No

SECTION 9: CONSENT & CONFIDENTIALITY

I understand that the information provided is confidential and will be used solely for the purpose of determining eligibility and coordinating care.

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Date
Month
Day
Year

© 2026 RECLAMATION HEALTH GROUP

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2900 W. Cypress Creek Rd

Suite 5-15

Fort Lauderdale, FL 33309

Info@reclamationcntr.com
P:954-343-6552

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Ready to Reclaim Your Life?

Taking the first step is the hardest part. We make everything after that as simple and supportive as possible.

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