www.virginiadetox.com - Commonwealth Addiction Treatment Center, L.L.C.

204 Hamilton Street, Suite #4 Richmond, VA 23221
(804) 353-1230 fax:(804) 353-3342 tollfree: 877-77DETOX

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877-77DETOX
(or 877-773-3869)

^*Your Name:

^*Patient Name:

^*Phone #:

^*Address:

^*City:

^*State:

^*Zip:

^*Email Address:

^*Date of Birth:

^*Age:

^*Support Person:

^*Phone #:

^*Referred by:

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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:	rare, mild, heavy
^*Cocaine:	rare, mild, heavy
^*Other:	rare, mild, heavy

Present:

^*Alcohol:	rare, mild, heavy
^*Cocaine:	rare, mild, heavy
^*Other:	rare, mild, heavy

^*Overdoses (how many):

^*Suicide Attempts (how many):

^*Past Medical History:
(any cardiac or respiratory problems?)

^*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:
^*Employment:	Full Time, Part Time, Unemployed
^*Job Title:
^*Job Description:

^*Additional Notes Pertaining to Detox:


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