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Admissions
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Services Offered
Crisis Stabilization
Secure Withdrawal Management Services
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Admissions Form
General Information
First Name
(Required)
Last Name
(Required)
Date of Birth
(Required)
Gender
(Required)
Address
(Required)
City
(Required)
State
(Required)
Zip
(Required)
Phone number
(Required)
E-mail
Substance Use History
Primary drug of choice
Last date of use (approximately)
Additional drug of choice (if any)
When are you looking to get into treatment?
Will you require transportation assistance?
Yes
No
Medical and Mental Health History
Are you pregnant?
Yes
No
Not Applicable
Do you have diabetes?
Yes
No
Do you have a history of seizures?
Yes
No
Do you currently have any medical conditions or concerns?
Yes
No
If yes to medical conditions, please list here
Do you have open sores, wounds, or lesions?
Yes
No
Have you been tested for MRSA?
Yes
No
Do you have a history of stroke or elevated blood pressure?
Yes
No
Have you had a recent injury, illness, or accident?
Yes
No
Are you capable of self-care? ex: eating, walking, dressing ect.
Yes
No
Are you on (MAT) Medication Assisted Treatment?
Yes
No
Are you capable of getting in and out of a 7-12 passenger van?
Yes
No
Do you need durable medical equipment?
Yes
No
Do you have any mental health conditions or concerns?
Yes
No
If yes, please explain
Do you have a history of self-harm or harm to others?
Yes
No
If yes, please explain
Do you have any known food or drug allergies?
Yes
No
If yes, please list here
Do you currently take prescribed medication(s)?
Yes
No
If yes, please list here
Are you capable of self-administrating medication as prescribed?
Yes
No
Health Insurance
Do you currently have health insurance coverage?
Yes
No
Insurance company
Insurance policy number
Date of expiration
Do you currently have a source of income?
Yes
No
Household/Family size
Emergency Contact Information
Emergency contact: First & last name
Emergency contact: Phone number
Relationship to client
Legal Representative, Power of Attorney, Protective Payee
Do you have a legal representative, power of attorney, or protective payee?
Yes
No
Comments
Admissions
Application Process
What To Expect
Payment Options
Family & Friends
Services Offered
Crisis Stabilization
Secure Withdrawal Management Services
Residential Treatment
Referrals
About Us
Contact Us
Careers
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