Dear Client:  We are glad you are here to visit us. You can use the links below to fill out forms before to be admitted to a program before you see us in the office. Remember, you must have an evaluation to know what level of care is recommended to help you best. If you haven’t had an evaluation yet, please click on this link to start the evaluation forms.

Once you submit your forms, please let us know that you did by emailing us at information@addsiowa.org and/or calling us at any of these locations listed on our homepage.

If you have any questions, don’t hesitate to call in for assistance or email us at information@addsiowa.org.


Coronavirus (COVID-19) Screener – Required for all evaluations, and all admissions until further notice.

Pre-Admission Forms

Application for Services (Pre-Admit)


Financial Determination / Client Insurance Sheet (Pre Admit)


– Informed Consent for Electronic Communication (Pre-Admit)

Admission Forms

Outpatient

Assessment Results and Recommendations Acknowledgement


Financial Determination / Client Insurance Sheet


HIV / STI Testing for Orientation Form


Informed Consent for Electronic Communication – Unscheduled version


Orientation Information (EOP)


Orientation Information (IOP)


OWI Class – OWI 321-J: Consent to Release of Alcohol and Drug Abuse Information

ROI Iowa Consortium


ROI Iowa WORKS Burlington, Iowa from ADDS to Iowa WORKS


ROI Iowa WORKS Burlington, Iowa from Iowa WORKS to ADDS


Tuberculosis Report


Residential

The below two forms are required for all residential admissions

*Download tobacco / nicotine and 60 Day acknowledgement here (Online form submission)

*Download tobacco / nicotine and 60 Day acknowledgement here (Paper form download)

*Supports for medical needs (Paper form download)

*Supports for medical needs (Online form submission)


Consent: Activities Outside the Treatment Center

Financial Determination / Client Insurance Sheet


Great River Medical Center Emergency Dept. Release – Treating Professional


Healthy Relationships Iowa Release


Hillcrest Family Services Release – Treating Professional


Hillcrest Family Services Release of Information – Administrative Staff Member

HIV / STI Testing for Orientation Form


Medication Risk Disclosure


Orientation Information (Residential)


ROI Iowa Consortium


ROI Iowa WORKS Burlington, Iowa from ADDS to Iowa WORKS


ROI Iowa WORKS Burlington, Iowa from Iowa WORKS to ADDS

Release of Information – Community Health Center Administrative Staff Member


Release of Information – Community Health Center Treating Professional for Physical


Release of Information – Heritage Park Pharmacy


Release of Information – Hy-Vee Pharmacy


Residential TB Form