Naukeag Form PDF Details

Seeking help for mental health and substance use issues requires courage and the first step often involves gathering the right information to facilitate access to treatment. The McLean at Naukeag Ambulatory Treatment Center Self-Referral Packet serves as a crucial tool for individuals seeking admission to their programs, embodying a detailed approach to ensure applicants provide comprehensive information necessary for a tailored treatment experience. This packet not only asks potential patients about basic identification details like name, age, gender, contact information, and preferred methods of communication but also delves deeper into critical areas such as presenting problems, past and current treatments, drug use history, medications, risk factors, legal issues, and aftercare plans. The form’s meticulous structure underlines the importance of understanding a patient’s entire background and current situation, from mental health diagnoses and substance use specifics to legal challenges and plans for aftercare, ensuring a holistic view is taken from the onset. Furthermore, it emphasizes the treatment center's commitment to patient-centered care, highlighting a need for patients to work on aftercare plans from the beginning of their admission and noting the realities of insurance-based decisions on treatment length. Filling out the self-referral packet is the first step of a journey toward recovery, promising a structured and supportive path forward for those reaching out for help.

QuestionAnswer
Form NameNaukeag Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesnaukeag self referral packet, naukeag ambulatory treatment, naukeag community referral, ambulatory treatment refferral

Form Preview Example

McLean at Naukeag Ambulatory Treatment Center Self-Referral Packet

1

 

NOTE: To be considered for admission application must be complete in full (If you need

 

assistance with the application call 978-827-5115 ask for admissions

 

How did you hear about Naukeag: ____________________________________

 

PATIENT INFORMATION

Have you been to Naukeag previously? … Yes … No

DATE: -----------------------------------

Are you being referred by any program or treatment provider? … N … Y (name): _________________________

Patient Name: __________________________________ Age_______ Gender: ______ DOB: ________________

Address: _________________________________________________ State/Country: _________ ZIP: __________

Email: ____________________________ Daytime phone #:____________________Cell #: __________________

Preferred method of contact: … Email … Phone … Cell … All Best time:___________________________

PRESENTING PROBLEM: Check all boxes that describe issues you are currently dealing with:

…alcohol problem … drug problem … depression … anxiety … trauma issues … suicidal ideation

…eating disorder … relationship conflict … housing/homelessness … anger management … ADD

…work issues

…school issues … grief issues

Briefly state why you are considering admission to Naukeag at this time:

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

CURRENT TREATMENT

Do you have current treatment providers? Y N Do you have a psychiatric diagnosis? _____________________

Name/Agency__________________________ therapist, psychiatrist, IOP, partial

Phone: ______________

Name/Agency__________________________ therapist, psychiatrist, IOP, partial

Phone: ______________

 

 

 

 

 

 

 

 

 

 

PAST TREATMENT (ADDICTION & MENTAL HEALTH)

 

 

 

 

 

 

 

Treatment Type

# of admits

Facility Name (of most recent treatment)

Dates

 

 

 

 

 

 

Detoxification

Inpatient Psychiatric

Residential

Halfway house

Sober House

Intensive Outpatient (IOP)

Outpatient therapy

Couple/family therapy

Suboxone, Methadone maintenance

Revised Nov. 2013/Feb 2016

McLean at Naukeag Ambulatory Treatment Center Self-Referral Packet

2

PATIENT NAME: ______________________________________

DRUG USE HISTORY

Primary Drug(s): ____________________________________ Secondary: __________________________

 

if used

 

Age

 

 

 

 

 

 

in the past

Drug

First Use

Last Use

Frequency

 

Amount

 

year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alcohol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Amphetamines

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Benzodiazepines

 

 

 

 

 

 

 

 

(Klonopin, Xanax, Valium Ativan)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cocaine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fentanyl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

GHB

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hallucinogens

 

 

 

 

 

 

 

 

(mushrooms, LSD, PCP, DXM)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heroin

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Inhalants

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ketamine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Marijuana

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MDMA (Ecstasy)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Methadone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Methamphetamine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Morphine

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Over the counter (cough syrup,

 

 

 

 

 

 

 

 

Asthma Inhalers, Laxatives, Diet

 

 

 

 

 

 

 

 

Pills, Cold Medicines, Ephedrine,

 

 

 

 

 

 

 

 

Sleeping Pills, Benadryl

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Oxycontin, Oxycodone, Percocet

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rohypnol

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Steroids (Anabolic)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suboxone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tobacco

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other:_____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICATIONS: List all current medications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL

Date of Last Physical:___________________________________

 

 

Primary Care Physician:_______________________________ Phone____________________________

List Any current medical conditions:

Revised Nov. 2013

McLean at Naukeag Ambulatory Treatment Center Self-Referral Packet

3

Name of Medication

Dosage

Reason Taking

PATIENT NAME: ______________________________________

RISK FACTORS

History of Suicide attempts

No

Yes: ______________________________________________________

 

Present Suicidal ideation

No

Yes: ______________________________________________________

 

Self-harm(past/present)

No

Yes: ______________________________________________________

 

Harm to others

No

Yes: ______________________________________________________

 

Fire-setting

No

Yes: ______________________________________________________

 

Access to firearms

No

Yes: ______________________________________________________

 

 

 

 

 

 

Trauma History

No

Yes: If yes do you feel that trauma may affect your recovery?

No

Yes

LEGAL

 

 

 

 

Any current legal charges

No

Yes: ______________________________________________________

 

On probation

No

Yes: ______________________________________________________

 

Upcoming Court Dates

No

Yes: ______________________________________________________

 

Restraining orders

No

Yes: ______________________________________________________

 

AFTERCARE PLANS- (Please note) Insurance companies decide length of stay, which is usually 10-12 days, once they deny approval you usually need to discharge the next day, so it is important to work on aftercare plans from the beginning of your admission.

HOUSING:

Return Home

Sober House

Residential Program

Friends

Homeless

Other ________________

 

Emergency Placement if needed to leave program unexpectedly:__________________________________________

TREATMENT:

Back to current providers

Partial

IOP

Individual Therapist/Psychiatrist

Group

Another Program

Self Help

Unsure

 

 

 

 

 

 

ANY ADDITIONAL COMMENTS: ____________________________________________________________________________

_____________________________________________________________________________________________________

*Upon completion of this application, Fax to: 978-827-4809. Call within 48 hrs 978-827-5115 (ask for John or Noelle). Applications will be kept on file for 10 days only. If appropriate, a telephone interview will be schedule with you. Applications are assessed for need, ability to participate successfully, motivation for sobriety and with meeting insurance criterion

Revised Nov. 2013

McLean at Naukeag Ambulatory Treatment Center Self-Referral Packet

4

 

 

 

 

 

 

Pre-Admit Form

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

 

 

 

Date: ____________Program:

 

ART or

 

PHP

 

 

 

 

 

 

 

 

 

 

 

 

•

 

 

 

 

 

Telephone #:____________________________________

Patient DOB:

 

 

Age:

 

 

 

 

 

 

 

 

 

Address:

 

 

 

City/State:

 

 

Zip: ______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary Insurance:

 

Telephone#:_______________________________

Insurance ID#:

 

Group# (if applicable): _____________________

*Subscriber Name: _________________________________________

*Subscriber DOB: ___________________________

 

 

 

 

Secondary Insurance:

 

 

Telephone#:_____________________________

Insurance ID#:

 

 

 

Group# (if applicable): ___________________

*Subscriber Name:

 

*Subscriber DOB: ___________________________

 

 

 

 

 

 

Pharmacy Information

In order to be prescribed medication at Naukeag the following information is required. If you don’t have a prescription card

call your pharmacy and they will be able to give you the information.

Cardholder I.D.: _____________________________________________ RxBIN: __________________________________

RxGroup: ____________________ Person Code: _____________ Pharmacy: _____________________________________

Town: ______________________________Phone Number: _________________________________

Do you have any allergies? ___________________________________________________________________________________

You are responsible for all co-pays which you may pay in cash or by credit card. The card number can be called into the pharmacy.

 

STOP PROGRAM USE ONLY

FAX TO PT ACCOUNTS 617-855-2366

 

 

 

Is Precertification Required? Y N

Telephone #: ___________________________________

Information Received:

 

 

 

 

 

 

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The way to prepare get naukeag get step 1

2. Right after filling out the previous section, head on to the next stage and complete the necessary details in all these blanks - Briefly state why you are, C URRENT TREATMENT D o you have, Na meAgency therapist psychiatrist, Do you attend self help Meetings, PAST TREATMENT ADDICTION MENTAL, Treatment Type, of admits, Facility Name of most recent, Dates, and Detoxification Inpatient.

Stage # 2 for filling in get naukeag get

3. Completing Detoxification Inpatient, and Revised Nov Feb is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Filling in segment 3 of get naukeag get

4. Your next paragraph will require your information in the subsequent places: McLean at Naukeag Ambulatory, PATIENT NAME, DRUG USE HISTORY, Primary Drugs Secondary cid if, Frequency, Amount, Drug, Age, First Use, Last Use, Alcohol, Amphetamines, Benzodiazepines Klonopin Xanax, Cocaine, and Fentanyl. Remember to fill out all of the requested info to go further.

Amount, Drug, and Amphetamines inside get naukeag get

As to Amount and Drug, be certain you take a second look here. Those two are considered the most important fields in this document.

5. The last section to conclude this form is pivotal. Make sure that you fill in the mandatory fields, including Hallucinogens mushrooms LSD PCP DXM, Heroin, Inhalants, Ketamine, Marijuana, MDMA Ecstasy, Methadone, Methamphetamine, Morphine, Over the counter cough syrup, Oxycontin Oxycodone Percocet, Rohypnol, Steroids Anabolic, and Suboxone, prior to using the form. Or else, it can result in an unfinished and possibly invalid paper!

How one can fill out get naukeag get portion 5

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