Dear Client: We are glad you are here to visit us. You can use the links below to fill out forms before you visit us in the office. Please read the instructions below carefully. If you have any questions, don’t hesitate to call in for assistance or email us at firstname.lastname@example.org.
Once you submit your forms, please let us know that you did by emailing us at email@example.com and/or calling us at any of these locations listed on our homepage.
- The information you provide us is confidential, will be used to help us serve you, and will not be shared with any third parties unless you give us permission to do so.
- To complete the forms, click on the form names below and a new window will pop up.
- Fill out each form COMPLETELY. Make sure to scroll through the whole form. Any questions, please ask! No signatures are given, yet.
- When you are done, click SUBMIT at the bottom of the form.
- After you complete each form, you will see a “return button.” Please do not use it, just click on the NextStep Forms tab to the top left of your screen.
Here for an evaluation? Please complete forms 1 – 5. Are you getting admitted today? Please complete forms 1-6.
3. Patient Health Questionnaire – 9 (evaluations only)
PHQ-9 Update (use if your counselor asked you to complete this)
Making a Referral to Peer Recovery
Community Agencies – Any community agency can make a referral to a peer recovery coach using this form!
EMS / Law Enforcement / First Responders – Any First Responder can make a referral to a peer recovery coach using this form!
Hospitals / EDs – Any Hospital / ED can make a referral to a peer recovery coach using this form!
Need Financial Assistance?
Please fill out our fee assistance application below. Click the link and download the form and print to bring it into one of our offices. You may also feel free to download this form as a PDF and fill it out on your computer and email it to staff in an office near you. Use this link to find the contact information for our staff.
You will need to follow all the instructions on the form or risk us rejecting the application.