Your answers are confidential and are used only by our admissions and clinical team to help you start care. "*" indicates required fields Step 1 of 17 5% EmailThis field is for validation purposes and should be left unchanged.If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Start Your AdmissionOutpatient care for addiction and mental health. This takes about 5 minutes. An admissions team member will review your answers and contact you to schedule your first visit. If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Who are you completing this for?* Myself A family member or loved one We will need to speak with the person seeking care before admission. Please answer as best you can.Your name*Your relationship to the person seeking care*Your phone* If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.These questions help us make sure outpatient care is the right fit and that you get help quickly if you need it. Please answer about the past month.In the past month, have you wished you were dead or wished you could go to sleep and not wake up?* Yes No In the past month, have you actually had any thoughts of killing yourself?* Yes No If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Have you been thinking about how you might do this?* Yes No Have you had these thoughts and had some intention of acting on them?* Yes No Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?* Yes No If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Have you ever done anything, started to do anything, or prepared to do anything to end your life? (For example: took pills, cut yourself, collected pills, obtained a weapon, wrote a note.)* Yes No Was this within the past 3 months?* Yes No If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.In the past month, have you had thoughts of seriously hurting someone else?* Yes No Your safety matters most right now.Based on your answers, outpatient care through this online form is not the right first step. Please call or text 988 (Suicide and Crisis Lifeline) now, call 911, or go to your nearest emergency room. If you can, stay with someone you trust. You can also call us at 1-888-505-1078 during business hours.Call or text 988Call 911Call 1-888-505-1078 If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Are any of these true for you right now? (check all that apply)* I have overdosed in the past 24 hours, or I have chest pain, trouble breathing, or confusion I have overdosed in the past 30 days I have had seizures, DTs (delirium tremens) or hallucinations when stopping alcohol, benzodiazepines (e.g., Xanax, Klonopin) or sleeping pills I currently drink alcohol every day or use benzodiazepines every day I am pregnant I am hearing or seeing things others do not, or I am having trouble taking care of basic needs like eating or staying safe None of these Thank you. A clinician may call you before scheduling to make sure we recommend the safest level of care. This may be a medical emergency. Call 911 now.If someone is not breathing or will not wake up, call 911 and give naloxone (Narcan) if you have it.Call 911 If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Are you currently receiving treatment for substance use or mental health from another provider or program?* Yes No Recently discharged (past 30 days) If you are already receiving treatment: please let your current provider or program know that you are seeking care with Outreach Recovery. Do not stop, change or combine any medication, including buprenorphine (Suboxone), methadone, or psychiatric medications, without talking to your prescriber first. Stopping some medications suddenly can be dangerous.If you are enrolled in a methadone program or receive buprenorphine from another prescriber, our team will need to coordinate with that provider before prescribing. With your written permission, we can request records and coordinate your care.Acknowledgment* I understand and will let my current provider know I am seeking care with Outreach Recovery. Type of current care (check all that apply) Methadone clinic Buprenorphine (Suboxone) prescriber Therapist or counselor Psychiatrist or psychiatric prescriber Residential or inpatient program Other If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.What brings you to Outreach Recovery? (check all that apply) Substance use: Alcohol Opioids, heroin or fentanyl Prescription pain medication Benzodiazepines Cocaine or crack Methamphetamine or other stimulants Cannabis Other substance Mental health: Depression Anxiety Trauma or PTSD Mood swings Stress or grief Other mental health concern Not sure If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.What type of outpatient treatment are you looking for? (check all that apply)* Medication-assisted treatment (MAT) Psychiatric evaluation and medication management Individual therapy and counseling Group therapy Family counseling Dual diagnosis (co-occurring) treatment Telehealth visits (where available) Toxicology and lab testing Not sure, please help me choose Final recommendations are made by our clinical team after your assessment. If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Outreach also offers other services. Are you interested in learning about any of these? Telewell wellness: weight support (GLP-1) Telewell wellness: hormone health (TRT and HRT) Telewell wellness: healthy aging, supplements and wellness packs Outreach Woundcare (Maryland) These are separate services. We will not share your answers on this form with them without your permission.Telewell wellness: weight support (GLP-1)Physician-guided weight support with nutrition, movement and follow-up, after medical review.telewell.fit | 410-504-6855Telewell wellness: hormone health (TRT and HRT)Evaluation, lab monitoring and follow-up.telewell.fitTelewell wellness: healthy aging, supplements and wellness packsEnergy, sleep and recovery support.telewell.fitOutreach Woundcare (Maryland)Physician-led wound care for chronic and non-healing wounds: evaluation and management, debridement, negative pressure wound therapy, clinic visits, in-home/mobile care and telemedicine.outreachwoundcare.com | 1-888-383-5613 If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Which location is most convenient?*Choose oneBaltimore, MDCatonsville, MDCumberland, MDEaston, MDFrederick, MDGlen Burnie, MDHagerstown, MDLaurel, MDLexington Park, MDPrince Frederick, MDWaldorf, MDEdison, NJMarlton, NJToms River, NJVineland, NJWoodbury, NJFredericksburg, VATelehealthNot sureHow would you like to be seen?* In person Telehealth if available Either Best time to reach you* Morning Afternoon Evening If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.How do you plan to pay for care?* Medicaid Medicare Private insurance Self-pay Not sure Please do not enter your member ID, Social Security number or card photos on this form.Insurance company name If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.How can our admissions team reach you?Name* First Last Date of birth*MMMM123456789101112DDDD12345678910111213141516171819202122232425262728293031YYYYYYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is the person seeking care 18 years or older?* Yes No We're sorry, Outreach Recovery can only admit adults 18 years or older, so we cannot accept this request.If you are in crisis, call or text 988 or call 911.Mobile phone*Email (optional) State*Choose oneMarylandNew JerseyVirginiaOtherIs it OK to leave a voicemail that says Outreach Recovery?* Yes No, use a generic message Is it OK to text you about scheduling?* Yes No If you are thinking about harming yourself or someone else, call or text 988, or call 911 now. Do not use this form in an emergency.Consent 1* I confirm the information I provided is accurate to the best of my knowledge. Consent 2* I understand this form is a request for admission, not a medical appointment, diagnosis or treatment. It does not create a patient relationship. Admission and level of care are decided by Outreach Recovery clinicians after an assessment. Consent 3* I understand this form is not monitored 24/7 and is not for emergencies. If I am in crisis I will call or text 988 or call 911. Consent 4* I agree that Outreach Recovery may contact me by phone, and by text if I selected Yes, about my request. Message and data rates may apply. Reply STOP to opt out. Consent 5* I have read the Privacy Policy and Notice of Privacy Practices. Privacy Policy and HIPAA Notice of Privacy PracticesCaptcha
