Medium

Available on

Apple Android Windows

Drug and Alcohol Intake Form Mobile App

The “Drug and Alcohol Intake Form” app is an efficient and safe app for performing the intake for a multi-disciplinary, integrated approach to the treatment of alcohol and other drug addiction and mental health disorders. It is very suitable for health care providers and other authorities that offer prevention and treatment of substance abuse and related disorders. The form fits well with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Drug and Alcohol Intake Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Client Number

  • Ico integer

    Social Security Number

  • Ico date

    New Date

  • Ico textbox

    Client’s Name (Last, First, Middle Initial)

  • Ico textbox

    Street Address

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico integer

    Zip Code

  • Ico integer

    Client’s Telephone Number - Home

  • Ico integer

    Client’s Telephone Number - Cell

  • Ico date

    Client’s Date of Birth

  • Ico textbox

    If client is a minor, parent/legal guardian’s name and SS#

  • Ico textbox

    Contact Person – Last, First, Middle, Subtitle

  • Ico textbox

    Contact’s mailing address:

  • Ico textbox

    City

  • Ico dropdown

    State

  • Ico integer

    Zip Code

  • Ico integer

    Contact’s Telephone #:

  • Ico dropdown

    Contact Relationship to Client:

  • Ico textbox

    Other:

  • Ico textbox

    Employer Name:

  • Ico integer

    Employer Phone #

  • Ico date

    Intake Date:

  • Ico textbox

    Staff Number

  • Ico textbox

    RU:

  • Ico textbox

    Staff Cost Center:

  • Ico dropdown

    CARF Follow-up

  • Ico dropdown

    entry status with the agency.

  • ...and More!

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