Intake Forms

Welcome to the intake paperwork to get you started with classes

Please fill out all the paperwork and email back to sregan@nullrangeviewcounselingcenter.com

If you need Level II 4 Plus program please fill out number 10 as well

1. Interstate-Compact-Client-Questionnaire
2. Consent to Treat
3. Release of Information
4. Michigan Alcoholism Screening Test (MAST)
5. Drug Use Questionnaire (DAST)
   
6. Addiction Severity Index
7. Staff Disclosure
8. Affidavit of Enrollment (DR2643)
   
9. Infectious Disease Questionnaire
10. Level II 4 plus TX.  Paperwork    –                                                                                                                                                                    –