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Report of addiction evaluation - dot.nd.gov 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by filling in the 'FROM' section with the name of the licensed addiction treatment program or counselor, along with their contact information.
- In the 'REGARDING' section, enter the patient's name, telephone number, address, and date of birth. Ensure all details are accurate for proper identification.
- Complete the 'VERIFICATION OF TREATMENT' section by indicating the enrollment date and completion date. Select the type of treatment received from the provided options.
- Have a qualified professional sign and date the form in the designated area, ensuring their license number is included.
- In the 'RELEASE OF INFORMATION' section, confirm your consent for information sharing by signing and specifying any expiration conditions for this consent.
- Finally, review all entries for accuracy before saving or printing your completed form for submission.
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