Better Together ND - Assessment Tool

Free Through Recovery Program

Please complete the following information:

First Name:

Middle Initial:

Last Name:

Please enter your phone number and date of birth:

Note: start typing in your phone number and it will be automatically formatted.

Phone Number:

Date of Birth:

Please enter your address:

Address (NOTE: Enter 'Homeless' if you are currently homeless):

City:

State:

Zip Code:

Fill out the appropriate client release and signature below:

I Hereby Authorize (My Parole or Probation Officer) To Represent Me:

To Disclose to and Mutually Exchange Information with (you do not have to fill this in):

Name of Agency (you do not have to fill this in):

The information below is requested.

(feel free to uncheck any, except for the first one):

Intake Assessment/Drug and Alcohol Evaluation and Diagnosis *required

Treatment Plan

Progress Reports

Aftercare

Psychiatric Evaluations and Psychiatric Medication

Drug/Alcohol Testing

Psychological Evaluations and Testing

Discharge Summary

Psychiatric and Psychological Notes and Diagnosis

Intake Impression and Referral

Family Workshop Information (Request for Contact)

Client Consent:

My authorization is voluntary and remains in effect until the expiration date unless specifically revoked by written notice. If my authorization is for disclosure to individuals within the criminal justice system who have made participation in a drug and alcohol treatment program a condition of the disposition of any criminal proceedings against me or my parole or other release from custody, I understand I cannot revoke my consent until there has been a formal and effective expiration of my sentence, release from confinement, or of my supervision on probation or parole, or other proceeding under which I was required to participate. Any information disclosed prior to the termination of this authorization is not a breach of confidentiality. A photocopy of this authorization is effective as the original. Unless otherwise agreed in writing, information may be disclosed under this agreement in any form or medium, including oral, written, or electronic transmission. By typing my name below, I am signing this application form electronically. I agree that my electronic signature is the legal equivalent of my handwritten signature.

Signature of Client:

Date:

Please also include your email so we can send you a confirmation email.

Email: