I understand that by submitting this form, I am initiating a request for substance use disorder services, and the information I provide will be protected under HIPAA and 42 CFR Part 2 as Protected Health Information (PHI). *

Personal Information

Which location are you applying for?

Which services are you interested in?

Who is filling out this form?

Yourself
Other contact

Have you been speaking to someone at My Next Step regarding admission?

Are you a former client of My Next Step?

Yes
No

Name (as shown on ID)

First

Last

Name you Prefer to be Called (if different than above)

First

Date of Birth

Age

Please enter a number from 16 to 99 .

Gender Identity

Marital Status

T-Shirt Size

Adult Unisex Sizes Available

Patient Phone

Patient Email

Patient Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Social Security Number

Our site uses SSL encryption, so your information is safe and stored confidentially.

Do you have a valid Driver's License, State ID or Passport?

Yes
No

Employment History

Applicant is currently employed
Applicant has been employed in the last six months
Applicant has been employed in the last year
Applicant has been employed in the last two years
Applicant has no employment history in over two years

Describe employment history including dates and industry:

Filing taxes can help keep your health insurance (subsidies) and may bring a refund. Would you like help with this?

Yes
No
More Information

Recovery Support System

By filling out the fields below, you are communicating that you understand the importance of your privacy and the confidentiality of your substance use disorder treatment records under 42 CFR Part 2 and HIPAA regulation. You acknowledge that your treatment success can be enhanced with the support of your family and/or invested social support people in your life, who play a critical role in your recovery and well-being

This consent authorizes My Next Step to disclose your substance use disorder treatment information to the family members and/or invested social support people in your life, strictly for the purposes of coordinating your care, including treatment, payment, and/or healthcare operations, and when deemed absolutely necessary by My Next Step.

Scope of Disclosure: The information disclosed may include, but is not limited to, treatment progress, atendance, and general well-being. Disclosures will be limited to situations where My Next Step determines that it is absolutely necessary for my treatment, payment, or the operations of the organization and will aim to support my recovery and care coordination.
Right to Revoke: I understand that I have the right to revoke this consent at any time by providing written notice to My Next Step, except to the extent that action has already been taken in reliance on it.
Expiration: This consent is valid for one year (365 days) from the date of signature, unless otherwise revoked.

Emergency Contact: First and Last Name

Emergency Contact: Phone Number (will be verified)

Emergency Contact: Relationship to Applicant

Recovery Support Contact #1: First and Last Name

Recovery Support Contact #1: Phone Number (will be verified)

Recovery Support Contact #1: Relationship to Applicant

Recovery Support Contact #2: First and Last Name

Recovery Support Contact #2: Phone Number (will be verified)

Recovery Support Contact #2: Relationship to Applicant

Legal Support Contact #1: First and Last Name

Legal Support Contact #1: Phone Number (will be verified)

Legal Support Contact #1: Relationship to Applicant

Insurance Information

Address

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Substance Abuse History

Please be as thorough as possible. Input information of up to three substances you are currently using. The details you provide below about your substance use or treatment history are confidential and protected as health information under federal law.

What led you to seek treatment now?

Have you been in recovery before?

Yes
No

Are you currently in substance use treatment (Inpatient or Outpatient)?

Yes
No

Substance

Age of first use

How often do you use this substance?

Average dose

Preferred route of administration

Last Use

Do you need to add more substances?

Yes
No

Do you have any other process addictions of concern?

Select all that apply. Or leave blank.

Gambling
Sex or Porn
Video Games or Social Media
Fitness or Working Out

Mental Health

The details you provide below about your substance use or treatment history are confidential and protected as health information under federal law.

Are you currently in mental health treatment?

Yes
No

Have you ever been in mental health treatment before (inpatient or outpatient)?

Yes
No

Have you ever had any previous psychiatric diagnosis? (depression, ADD, bipolar, PTSD)?

Yes
No

Do you have a history of trauma?

Yes
No

Have you ever had issues with disordered eating?

Yes
No

Medical History

Answers will not necessarily disqualify you from treatment. These are only to better understand how we can best meet your specific needs. The details you provide below are confidential and protected as health information under federal law.

Do you have any history of withdrawal symptoms?

Yes
No

Have you ever been on Anti-Craving medications? (Vivitrol, Naltrexone, Campril, and/or Antabuse)?

Yes
No

Are you currently on Suboxone or Methadone maintenance?

Suboxone
Methadone
No

Do you have any medical conditions?

Yes
No

Have you been hospitalized in the past 30 days?

Yes
No

Any physical limitations to activities of daily living (medical devices, dietary restrictions, etc.)?

Yes
No

Allergies (medication/food/environmental/seasonal)?

Yes
No

Are you currently prescribed any medication?

Yes
No

Emotional/Behavioral Risk Screening

Answers will not necessarily disqualify you from treatment. These are only to better understand how we can best meet your specific needs. The details you provide below are confidential and protected as health information under federal law.

In the past month, have you wished you were dead or wished you could go to sleep and not wake up?

Yes
No

In the past month, have you actually had any thoughts of killing yourself?

Yes
No

Have you ever done anything, started to do anything, or prepared to do anything to end your life? (e.g. collected pills, obtained a gun, gave away valuables, wrote a will or suicide note; took pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.)

Yes
No

Do you have a history of self-harm behaviors?

Yes
No

Do you have anger issues?

Yes
No

Legal Issues

Answers will not necessarily disqualify you from treatment. These are only to better understand how we can best meet your specific needs. The details you provide below are confidential and protected as health information under federal law.

Are you currently on probation?

Yes
No

Do you have any active warrants you are aware of?

Yes
No

Are you a sex offender?

Applicant understands My Next Step may run a national sex offender search during the application process.

Yes
No

Any additional legal issues?

Yes
No

Are you a participant of any Specialty Court (Drug Court, Family Court, Veterans Court, etc. )

Yes
No

General

How did you hear about us?

Name of Doctor/Counselor?

Are you planning to reside in Transitional Supportive Clinical Housing?

Yes
No
Unsure

If yes, please note:

Housing is a structured component of the My Next Step clinical continuum and requires active participation in clinical services.

Monthly housing fees apply. If you believe you may require financial assistance for housing, you may request a separate Housing Financial Hardship Application after admission determination.

I Understand.

Name

First

Last

Date

File

Apply for Services

Personal Information

Recovery Support System

Insurance Information

Substance Abuse History

Mental Health

Medical History

Emotional/Behavioral Risk Screening

Legal Issues

General

Thank you, our team will contact you shortly.