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Click ‘Get Form’ to open the naukeag referral packet 2013 in the editor.
Begin by filling out the 'Patient Information' section. Enter your date, name, age, gender, and contact details. Make sure to indicate if you have been referred by another program.
In the 'Presenting Problem' section, check all applicable boxes that describe your current issues. Provide a brief explanation of why you are considering admission at this time.
Complete the 'Current Treatment' section by indicating whether you have treatment providers and listing their names and contact information.
Fill out the 'Drug Use History' by detailing your primary and secondary drug use, including frequency and last use dates.
List all current medications in the 'Medications' section along with their dosages and reasons for taking them.
Address any risk factors and legal issues as required in their respective sections.
Finally, complete the 'Aftercare Plans' section to outline your post-treatment plans before submitting your application.
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Naumkeag is also the term for a Native American settlement at the time of English colonization in present-day Salem, Massachusetts, meaning fishing place, from namaas (fish), ki (place) and age (at) or by another translation eel-land. However, the settlement Naumkeag was only one of a group of politically connected
What is on a referral form?
It includes information about the referring provider, the patients personal information, the reason for referral, referral details, and additional medical information.
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