Please complete to start our approval process: *

First Name

Last Name

Phone *

If you don't have a phone, please put 000-000-0000

(###)

###

####

Date of Birth *

MM

DD

YYYY

Gender Identity

Male

Female

Prefer Not To Answer

What substances have you used in the past 30 days? *

Check all that apply

Alcohol

Opiates(oxy, heroin, fentanyl, pain pills, morphine, etc.)

Methamphetamines or Amphetamines

Benzos

Cocaine or Crack

Marijuana

Other- Please explain below

Are you currently experiencing withdrawal symptoms? *

Yes

No

Have you ever had to be medically detoxed?

Yes

No

Do you have any medical concerns? Either diagnosed or undiagnosed *

Yes

No

Do you have a history of Traumatic Brain Injurys? *

Yes

No

Have you had any recent surgeries? *

Yes

No

Do you have any open wounds? *

Yes

No

Are you Pregnant?

Yes

No

Do you have any allergies *

Yes

No

Are you/ should you be taking any medication?

Yes

No

Do you have any mental health concerns? Either diagnosed or undiagnosed? *

Yes

No

Have you been incarcerated in the past 30 days?

Yes

No

Is someone telling you that you must complete treatment?

No- I am referring myself

Court

Child Protective Services

My Probation or Parole Officer

My Family

I am on commitment

Other- Please explain below

Describe your living environment

Homeless- No fixed address (includes shelters)

Dependent living- Dependent children and/or adults living in a supervised setting

Independent living- including on own, self supported, and non-supervised group homes

Children living with their family

Do you have medical insurance?

Yes

No

Do you have a Primary Care Provider?

Yes

No

Do you require any special accomodations?

Yes

No