Recovery Program Data Packet


1258 High Street, Eugene, OR 97401

Phone 541-342-8437 | Fax 541-242-2999

Recovery Program Data Packet

**Please complete this form for the person who is receiving services.**

Legal Name:    Last Name at Birth:

Preferred name:   Date of Birth:

Name of person completing form (if other than client):

Name and relationship of referral source:

Physical Address:   City, State, Zip:

Mailing Address (if different):   City, State, Zip:

Contact Information

Primary phone number:   Number belongs to:

Primary phone type:

OK to leave a message?

OK to identify we are calling from CFD?

Alternate phone number:   Number belongs to:

Alternate phone type:

OK to leave a message?

OK to identify we are calling from CFD?

How would you like to receive appointment confirmations?

Send confirmations to:

By marking yes to receive appointment confirmations by text in the box above, I request that confirmation of my appointments be done by text message. I understand I will not receive confirmation by telephone calls. If my text message number changes, I will notify CFD. I am aware that information contained in text messages cannot always be guaranteed to remain confidential due to the limitations of electronic media.

Gender as Specified on Insurance:

Gender Self-Identification, if different:

Preferred pronouns:

Race

Ethnicity

 

Living Status

 

Tribal Member:

If yes, enter Tribe Name:

Marital Status:

Tobacco Use:

If yes, which type(s)?

Smoking Status

 

Language

Preferred Language:

Is a translator needed?

Military Status: Are you currently serving in the military?

 

Legal Issues

Arrest History

Number of Arrests in Past Month:   Total Arrests:
Number of DUII Arrests in Past Month:   Total DUII Arrests:

Substance Use in Last 90 Days:

Employment Status

 

Education:          Highest grade completed:

Household Income

Estimated gross household yearly income: $

Number of people supported by household income (including self):

Number of child dependents (ages 0-17 supported by household income):

Principle Income Source

 

Emergency Contact Information

Name:    Relationship:

Address:   Phone number:

Medical Information

Primary Care Physician’s Name (PCP):

Phone:   Fax:

When was the last time you saw your PCP?

Dentist’s Name:

Phone:   Fax:

Psychiatrist/Psychiatric Nurse Practitioner Name:

Phone:   Fax:

Women Only

Are you pregnant?

If pregnant, are you receiving prenatal care?

If yes, who if your prenatal healthcare provider?

Phone:   Fax:

DUII Clients Only

Oregon Driver’s License or I.D.# if no license:

Some people experience things that make life more difficult. Please check those the things listed below that you are concerned about:

Please list current mental health, drug/alcohol and/or gambling services you are receiving:

Leave this empty:

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Document name: Recovery Program Data Packet
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Timestamp Audit
April 17, 2020 9:12 am PSTRecovery Program Data Packet Uploaded by Do Not Reply - donotreply@c-f-d.org IP 65.157.96.202
April 29, 2020 8:39 am PSTRecords Department - records@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
April 29, 2020 9:37 am PSTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 71.238.126.129
May 5, 2020 9:33 am PSTCFD Main - main@c-f-d.org added by Jason Dooley - jdooley@c-f-d.org as a CC'd Recipient Ip: 173.8.200.225
March 18, 2021 2:02 pm PST Document owner jdooley@c-f-d.org has handed over this document to donotreply@c-f-d.org 2021-03-18 14:02:07 - 65.157.96.202
March 18, 2021 2:02 pm PSTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
May 3, 2021 10:37 am PSTCFD Main - main@c-f-d.org added by Do Not Reply - donotreply@c-f-d.org as a CC'd Recipient Ip: 65.157.96.202
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