OTC Forms

OTC Forms 2016-12-06T12:39:40+00:00

Opioid Treatment Center Application

  • General Applicant Information

  • How did you hear about us?
  • Treatment History

  • History of Drug/Alcohol Treatment: Residential, Hospital, Outpatient,. Please do not include Detox or DUI.
    ***You may press the (+) button to the far right of each column to add rows.
  • Name of ProgramDates Attended TreatmentType of Treatment 
    Add a new row
  • Name of Program (copy from box and/or boxes above)How Long in TreatmentLength of Treatment Program 
    Add a new row
  • When?What type of treatment? 
    Add a new row
  • Examples of these conditions are, but not limited to, depression, anxiety, panic, schizophrenia, bipolar, etc.
    Add a new row
  • List Current MedicationsHow Often Do You Take These Medications?Strength of Medication (e.g., mg) 
    Add a new row
  • Substance Use History

  • List all substances used including alcohol, tobacco, marijuana, illegal drugs and prescription drugs. Please list in the order of use starting with current use at the top.
    ***You may press the (+) button to the far right of each column to add rows.
  • Substance UsedYears of UseRoute (oral, nasal, IV) 
    Add a new row
  • Substance Used (copy from box and/or boxes above)Amounts per Day/WeekLast Use (Date) 
    Add a new row
  • Legal History

  • ***You may press the (+) button to the far right of each column to add rows.
  • Name of charge, arrest or convitionWhen did this occur (year) 
    Add a new row
  • Probation/Parole Officers NamePhone Number 
  • If 'Yes', you will need to provide documentation of previous sex offender treatment.
  • Medical Information

  • ***You may press the (+) button to the far right of each column to add rows.
  • ConditionDate DiagnosedWho Diagmosed 
    Add a new row
  • Condition (copy from box and/or boxes above)Medication for ConditionCurrent: Yes or No 
    Add a new row
  • Written Response Section

  • For each of the following questions, please give complete answers in paragraph form. Answers should range between 3-5 sentences each.
  • Reminder To All Applicants, Please Note:

    • If you have a copy of a psychiatric evaluation completed in the last year, further documentation will need to be provided.
    • If you are a registered sex offender, you will need to provide documentation of treatment.
    • It is important to your care and treatment that you fill out the application completely.
    • Feel free to add additional paperwork you consider helpful or necessary.