First Name

Last Name

Middle Initial

GenderMaleFemale

Birth Date

Age

Marital Status MarriedDivorcedSeparatedSingleOther

Address

City

Zip Code

County

State

Home Phone

Insurance Provider

Veteran Service

Education Grade 12 or GEDCollege4 Year UniversityTrade SchoolOther

Do you have any Allergies? NoYes

If “yes” please describe

Contact Person

Contact Person’s Phone #

Relationship

Address

City/State/Zip

Telephone

Home

Other

1st Preference AlcoholHeroinPrescription NarcoticsCocaineCrack CocaineBenzodiazepinesMarijuanaAmphetamine

Age of 1st use

Last date of use

2nd Preference AlcoholHeroinPrescription NarcoticsCocaineCrack CocaineBenzodiazepinesMarijuanaAmphetamineNoneOther

Age of 2nd use

Last date of use

3rd Preference AlcoholHeroinPrescription NarcoticsCocaineCrack CocaineBenzodiazepinesMarijuanaAmphetamineNoneOther

Age of 3rd use

Last date of use

Number of prior treatments

Number of prior treatment at QBH:

Have you had legal issues?

If you selected “Other” for any of the above choices, please provide drug type here:

Notes/Comments: