33 Wentworth Ave E, Ste 180, West St. Paul, MN 55118
Mon–Fri: 8:30 AM – 4:00 PM
(952) 960-9476
Info@nrcmn.com
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Rule 25 Assessment
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Start Your Rule 25 Assessment Here
Complete the form below. Our team will contact you to schedule your assessment.
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Name
Date of Birth
Street Address *
City *
State *
Zip *
Phone No
Alternate Phone
Email ID *
What is your reason for calling today?
Do you have Health Care Insurance? Provider (choose one)
MEDICA
BC/BS
PREF ONE
HP UCARE
MEDICA MHP
Hennepin Health
CCDTF/MA
PMI#
Medical ID#
Group#
Who referred you to us?
PO/Parole Officer
Courts
Family/Friend
Another TX Center
Other
Self Referral
If treatment is recommended, is there a provider you would prefer?
What consequences have you had as a result of your alcohol and/or drug use?
Rule 25 Assessment
Have you had an assessment or Rule 25 in the past 45 days?
Yes
No
Is someone requiring you to receive a Rule 25 assessment?
Yes
No
Substance Use
What is your drug of choice?
Date of Most Recent Use
Amount
I consent to receive telephone calls and Short Message Service (SMS) text messages from Nova Recovery Center, Inc. at the telephone number(s) I have provided, for purposes of appointment reminders, treatment coordination, and other healthcare-related communications. Message and data rates may apply. I may revoke this consent at any time by contacting Nova Recovery Center.
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