| Reduced Fee Drug Screening
Voucher (Municipal) |
| |
| Client Name: |
|
Court Case # (JD, CM, CF) |
|
| Client Phone: |
|
(DHS, CW Only), KK#: |
|
| Referral Name: |
|
Phone: |
|
| Email: |
|
|
| Drug Screening Program Options:
(Check all that apply) |
|
One time
Test: |
| |
Urinalysis: (One Panel) |
Reduced Fees ($15) |
Drug Requested: |
| |
(7 Panel, Results in 24-48 Hours) |
Reduced Fees ($20) |
|
(7 panel
test - alcohol, THC, cocaine, amphetamine, opiates, methamphetamine,
benzodiazepines, & barbiturates) |
| |
Hair Follicle:
(Results in 2-3 Days) |
Reduced Fees ($80) |
|
| |
(Hair Follicle Testing can
detect regular drug use over a 90 day period, 5-panel test -
cocaine, amphetamines, opiates, thc, & pcp) |
| |
|
|
|
Random
Testing: |
| Random Schedule will consist of
... |
tests per month for
month(s) |
| OR... |
tests per week for
month(s) |
| (Do you want the client to
test?): |
5-days
(M-Fri) a week, or
7-days
(M-Sun) a week. |
| |
Urinalysis: (One Panel) |
Reduced
Fees ($8) |
Drug Requested: |
| |
(7 Panel, Results in 24-48 Hours) |
Reduced Fees ($25/13) |
|
(7 panel
test - alcohol, THC, cocaine, amphetamine, opiates, methamphetamine,
benzodiazepines, & barbiturates) |
| |
Hair Follicle:
(Results in 2-3 Days) |
Reduced Fees ($80) |
|
| |
(Hair Follicle Testing can
detect regular drug use over a 90 day period, 5-panel test -
cocaine, amphetamines, opiates, thc, & pcp) |
| |
Saliva Test: (Results in
2-3 Days) |
Reduced Fees ($20) |
|
| |
(6-panel test - thc, cocaine,
amphetamine, opiates, methamphetamine, pcp) |
| |
ETG Alcohol Testing: |
Reduced Fees ($35) |
+ 7
Panel ($40) |
| |
|
|
|
Additional Drugs Requested: (Check here if you want additional drugs
tested). |
| Additional fees apply. Fees are dependent on # of
additional tests requested. |
| Drug Requested: Drug Requested:
|
|
Adulteration Testing: (Check here if you think the client is
tampering or masking their samples) |
| Additional fees apply. Detects the use of masking
agents, bleach, and other methods clients try to use to cover up or
hide their drug use. |