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CALL: 651-340-7386

Assessments and Outpatient Treatment Pre-Screen Form

Name (first, last and middle initial)

Today's Date

Birthday

Month

Day

Year

Phone

Are you homeless and seeking housing?

If you do not have a permanent address leave address blank

Street Address

City

State

Zip Code

County

Email

Please contact me to schedule an assessment

I am seeking outpatient treatment

Do you have insurance?

Select which type of insurance you have*

*We do not accept HealthPartners

Are you currently on probation?

Do you use opiates?

Tell us more:

I am using and need access to Naloxone, Medically Assisted Treatment and harm reduction resources.

I used in the past but have been clean for more than three month

CALL: 651-493-2782

FAX: 651-493-2782

©2025 by Lotus Recovery.

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