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.
Pre-Admission Forms
Application for Services / Financial Form (Pre-Admit)
– Informed Consent for Electronic Communication (Pre-Admit)
Admission Forms
Outpatient
Application for Services / Financial Determination (Unscheduled Form)
HIV / STI Testing for Orientation Form
Informed Consent for Electronic Communication – Unscheduled version
OWI Class – OWI 321-J: Consent to Release of Alcohol and Drug Abuse Information
ROI Iowa WORKS Burlington, Iowa from ADDS to Iowa WORKS
ROI Iowa WORKS Burlington, Iowa from Iowa WORKS to ADDS
Residential (* means required pre-admission)
*Coronavirus (COVID-19) Residential Screener Must Be Completed
*Fill out the Tobacco/Nicotine Acknowledgement Form (Online form submission)
*Download the Tobacco/Nicotine Acknowledgement Form (Paper Form Download)
*Violence Risk Screening (V-RISK 10) (Paper form download)
*Fill out the Violence Risk Screening (V-RISK 10) (Online form submission)
Consent: Activities Outside the Treatment Center
Application for Services / Financial Determination (Unscheduled Form)
Great River Medical Center Emergency Dept. Release – Treating Professional
Hillcrest Family Services Release – Treating Professional
Hillcrest Family Services Release of Information – Administrative Staff Member
HIV / STI Testing for Orientation Form
Orientation Information (Residential)
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