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Admission Form for Path to Recovery
Admission Form
First Name
Last Name
Email
Date of Birth
Address
City
State
ZIP Code
What is your reason for calling today?
Do you have Health Care Insurance?
Yes
No
Select Provider
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MEDICA
BC/BS
PREF ONE
HP UCARE
MEDICA MHP
Hennepin Health
CCDTF/MA
WHO REFERRED YOU TO US?
PO/Parole Officer
Courts
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Another TX Center
Other
Self Referral
If treatment is recommended is there a provider you would prefer?
Evening or Weekend?
What consequences have you had a result of your alcohol and/or drug use?
Have you had a assessment or Rule 25 in the past 45 days?
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Yes
No
Is someone requiring you to receive a rule 25 assessment?
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Yes
No
What is your drug of choice?
Date of Most Recent Use
Amount
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