How can we help?

First name

Last name

Birthday

Month

Day

Year

Address

Phone Number

Which level of care do you/your client need?

Briefly describe why you need help with substance use treatment.

Identify which substances you have used / currently using

Alcohol: One of the most prevalent substances treated, involving specialized detoxification protocols and long-term relapse prevention.

Opioids: Includes illicit narcotics like heroin and fentanyl, as well as prescription pain relievers (e.g., oxycodone, hydrocodone).

Stimulants: Includes illicit stimulants like cocaine and methamphetamine, as well as prescription stimulants (e.g., ADHD medications).

Cannabis: Programs treat cannabis use disorder, often focusing on high-potency THC products.

Sedatives, Hypnotics, and Anxiolytics: Includes prescription anti-anxiety medications and sleep aids like benzodiazepines and barbiturates.

Hallucinogens: Includes classic psychedelics (e.g., LSD, psilocybin) and dissociative drugs (e.g., PCP, ketamine).

Inhalants: Volatile substances found in household products like solvents, aerosols, and gases.

Nicotine / Tobacco: Frequently integrated into comprehensive SUD programs to promote overall health and recovery.

Other

Please provide your Medical Assistant number

(this is used to determine your eligibility as an alternative method)

Please provide your SSN #

(this is used to determine your eligibility as an alternative method)

Please put current date

Month

Day

Year

If person other than person above please provide your relationship to the person above, title, name, phone, number and email address and credentials if applicable.

Please put N/A if self referral

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

By signing above you give Sunnyside Behavioral Health consent to verify your information to confirm program eligibilty.