TiOAT Application - Ask Wellness

TiOAT Referral

Client Name:

Preferred Name:

Birth Date:

Preferred Gender Pronoun:

Is the client in supported housing? (Include organization name, type, contact):

Primary Physician / care team:

Is the client aware of this referral?

Yes

Contact Information - What is the best way to contact the client?

Client Contact Number:

Referrer Name:

Position:

Contact:

Other teams / community supports involved:

Medical History:

Current Medications:

Substance Abuse History:

Opiods:

Current Use (amount, frequency, route):

Age at first use:

Overdose History

OAT Treatment History (highest methadone/kadian dose, suboxone, duration of treatments, reason for discontinuing, etc.):

Alcohol

Current Use (amount, frequency):

Stimulants

Current Use (amount, frequency, route):

Benzodiazepines

Current Use (amount, frequency):

Other (GHB, LSD, MDMA, etc.):

Current Use (amount, frequency):