Online Alcohol Drug Screening

Your Name (required) *

Date of Birth

Last 4 Digits of Social Security #

Maiden Name

Race

Ethnicity

Phone Number (required) *

What County Do You Reside In? (must be in North Carolina) *

Address (street, city, zipcode)

Your Email (required) *

Marital Status

Family Size

Gender

Male

Female

Your Primary Language

Your Living Arrangement

Employment Status

Annual Family Income

Are You a Veteran?

Yes

No

Do You Have Medicaid?

Yes

No

Carolina ACCESS Medicaid?

Yes

No

Do You Have Insurance?

Yes

No

Medicaid Number

(if applicable)

Carolina ACCESS Physician Name:

(if applicable)

INSURANCE Information (if applicable):

(list insurance name, and your member #)

Online Substance Abuse Screening Tool

Request A Counselor Callback: This Service is for Asheboro and Greensboro, NC Area Clients Only

Medicaid or Insurance (if applicable)

Drugs of Abuse - check substances below you have used

Prior Treatment Episodes for Substance Abuse

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