The Coleman Institute - Opiate Detox Form

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*Required Fields
	Your Name*:
	Patient Name*:
	Address*:
	City*:
	State/Province*:
	Zip/Postal Code*:
	Phone*:
	Email*:
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	Date of Birth*:
	Age*:
	Support Person*:
	Support Phone*:
	Referred by*:

	Please indicate which service you are requesting*:	Opiate Detoxification Alcohol Detoxification Naltrexone Implant/Injection Alcohol Addiction Treatment Benzo Addiction Treatment Cocaine Addiction Treatment

	Current PCP or Specialist Name*:
	Phone*:
	Current Counselor/Psychiatrist Name*:
	Phone*:
	Aftercare Treatment Plan*:
	Pharmacy Phone*:

	Current Daily Opiate Use*:
	Amount Used Daily*:
	Means of Use*:	Snort IV Other
	First Opiate Use*:
	Age When Started*:
	Previous Substance Abuse*:
	Previous Drug Treatment*: (when and how long was abstinence?)
	Legal Problems*:
	Previous Methadone Use*:	Yes No
	If Yes, how much*:
	Other Drug Use in the Past and Currently*:
	Past Alcohol Usage*:	None Rare Mild Heavy
	Past Cocaine Usage*:	None Rare Mild Heavy
	Past Usage of Other Substances*:	None Rare Mild Heavy

	Present Alcohol Usage*:	None Rare Mild Heavy
	Present Cocaine Usage*:	None Rare Mild Heavy
	Present Usage of Other Substances*:	None Rare Mild Heavy

	Overdoses*(how many):
	Suicide Attempts*(how many):

	Past Medical History*:
	Current Medications*:
	Allergies to Medications*:

	Family History*:	Mother (age):
		Father (age):
		Siblings (age):
	Family Hx S/A*:	MA side:
		PA side:

Family Medical History*:
Mother: (please list any medical conditions or problems)

Father: (please list any medical conditions or problems)

	Social History*:	Married:
		Children:
		Lives with:
		Smoke: (packs per day)
		Pregnant: LMP:

	Employment*:	Full Time Part Time Unemployed
	Job Title*:

	Job Description:
	Additional Notes Pertaining to Detox:

When you click a submit button, this information will be transferred to The Coleman Institute. Depending on your location, submit your information to either the Virginia, California or Kentucky office location:

Illinois

Virginia

California

Kentucky


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