Sign up for
NAFFA Wellness

The NAFFA Wellness Intensive Virtual Program

offers 3 hours classes (morning or evening)

available Tuesday, Wednesday, Thursday

NAFFA Wellness puts the security of the client at a high priority. Therefore, we have put efforts into ensuring that the information you send is safe and only seen by authorized staff, if you have any questions, please do not hesitate to reach out to NAFFA Wellness staff.

NAFFA WELLNESS REGISTRATION

Referring Agency Information

Date

Email

Agency & Name/Title

Fax

Phone Number

Address

Client Demographics

Name

Date of Birth

Alt. Phone Number

How did you hear of NAFFA?

Preferred Contact

Tribal Affiliation

Access to internet or phone to participate in telehealth or groups?

Highest Level of Education

Voluntary Referral

Phone Number

Disabilities

Emergency Contact

Name

Phone Number

Legal

Court invovled?

Sex Offener?

Social Services Involved?

Probation Involved?

Currently Incarcerated?

Legal Invovlement Details

Probation / Parole Officer / Case Worker / Court Contact

Name

Phone

Fax?

Address

Presenting Problem:

Symptoms

Safety Elements

Suicide Attempt

Current

Over a year ago

Denies

Physical Aggressions

Current

Over a year ago

Denies

Suicidal Ideations

Current

Over a year ago

Denies

Sexual Perpetration

Current

Over a year ago

Denies

Self - Harm

Current

Over a year ago

Denies

Other

Current

Over a year ago

Denies

Describe history and identify safety risks

Alcohol

Age of first use

Marijuana

Age of first use

How often is drug taken?

When was last use?

How often is drug taken?

When was last use?

Spice (K2 synthetic THC)

Age of first use

How often is drug taken?

When was last use?

Cocaine

Age of first use

How often is drug taken?

When was last use?

Heroin

Age of first use

How often is drug taken?

When was last use?

Prescription Opiates

Age of first use

Fentanyl

Age of first use

How often is drug taken?

When was last use?

How often is drug taken?

When was last use?

Methamphetamine

Age of first use

How often is drug taken?

When was last use?

Dextromethorphan (Triple C’s)

Age of first use

How often is drug taken?

When was last use?

Hallucinogens

Age of first use

How often is drug taken?

When was last use?

Anabolic Steroids / PEDs

Age of first use

How often is drug taken?

When was last use?

Other

Age of first use

How often is drug taken?

When was last use?

Describe history and identify substances

Additional items requested: Tribal ID, CIB, or Letter of Tribal Affiliation (if available)

Thanks for submitting!

Sign up for NAFFA Wellness

​

NAFFA WELLNESS REGISTRATION

Referring Agency Information

Client Demographics

Emergency Contact

Legal

Probation / Parole Officer / Case Worker / Court Contact

Presenting Problem:

Symptoms

Safety Elements

Sign up for
NAFFA Wellness