Name
*
First Name
Last Name
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
MM
DD
YYYY
SSN
*
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Phone (Home/Cell)
*
(###)
###
####
Phone (Work)
(###)
###
####
Employer and Occupation
How did you hear about Ekam Recovery? If referred, please list facility or provider name.
*
Name
*
First Name
Last Name
Relationship to Patient
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
*
(###)
###
####
Policyholder's Name
Relationship to Patient
First Name
Last Name
Policyholder's Date of Birth
MM
DD
YYYY
Policyholder Address (if different than above)
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Plan Type
Policy Number
*
Group Number
Claims Address (Street Address, City, State, & Zip)
Credit Card Type
*
Other - Card Type
Cardholder's Name
*
First Name
Last Name
Card Number
*
CVV
*
Expiration Date
*
Zip Code
*
What would you like to achieve by engaging in IOP at this time?
*
Have you previously undergone treatment or counseling for drug or alcohol addiction? If yes, please provide details.
*
What substances have you used in the last three months?
*
Detail frequency, amount, method of use, & date of last use for all substances check marked above.
*
Are you currently on any prescription medications or undergoing medication assisted treatment? Please list medication, dosage, and how long you have been taking the med(s).
*
