Please complete to start our approval process:
*
First Name
Last Name
Email
*
Phone
*
If you don't have a phone, please put 000-000-0000
(###)
###
####
Date of Birth
*
MM
DD
YYYY
Social Security Number
*
Is someone telling you that you must complete treatment?
Gender Identity
*
Male
Female
Transgender
Other Identity
Prefer Not to Answer
Race:
*
African American
American Indian or Alaskan Native
Asian
Caucasian
Mixed
Native Hawaiian/ Pacific Islander
Other
Hispanic Ethnicity
Not of Hispanic Origin
Puerto Rico
Mexico
Cuban
Other
In the past 30 days, Where have you been living most of the time?
Homeless- no fixed address or shelter
Dependent Living- Such as inpatient/ Residential
Independent Living- Own home/apartment
Unknown
Child living with family
Current Marital Status
*
Single, Never Married
Co-habiting / Living with significant other
Married
Separated
Divorced
Widowed
Unknown
Do you have children under the age of 18?
Yes
No
Education (select highest level)
Grade School
Some High school, did not graduate
High School/GED
Some College, No degree
Associates Degree/ Vocational Certificate
Post Graduate/ Professional Degree
Unknown
Have you been incarcerated in the past 30 days?
*
What substances have you used in the past 30 days?
*
Check all that apply
Are you currently experiencing withdrawal symptoms?
*
Have you ever had to be medically detoxed?
Are you Pregnant?
Do you have any medical concerns? Either diagnosed or undiagnosed
*
Do you have any open wounds?
*
Have you had any recent surgeries?
*
Do you have any allergies
*
Do you have a history of Traumatic Brain Injurys?
*
Are you/ should you be taking any medication?
Do you have any mental health concerns? Either diagnosed or undiagnosed?
*
Do you have medical insurance?
Do you have a Primary Care Provider?
Do you require any special accomodations?
