Naukeag Form – Fill Out and Use This PDF

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Naukeag Form PDF Details

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Question	Answer
Form Name	Naukeag Form
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	naukeag 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

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

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

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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1. When filling out the the naukeag online, make sure to incorporate all needed fields within the relevant area. It will help facilitate the work, allowing for your details to be handled quickly and correctly.

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!

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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Naukeag Form – Fill Out and Use This PDF

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