Admission Application

Your Name *

Client Name (if different)

Email *

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

In Treatment?

Current Treatment Facility Name

Hospitalizations in past 2 years? *

Explain Hospitalizations *

Reason Seeking Treatment

Substance Use History

Detox Needed *

Needing Detox From What Substance *

Any Current or Past Suicide Attempts or Self-Harm Episodes? *

Most Recent Suicide Attempt or Self-Harm Episode? *

History of Trauma? *

Type of Trauma?

Legal Issues? *

Terms of Release

Terms of Probation

Medical Conditions? *

Explain Medical Conditions *

Currently on Medication? *

Current Medications? *

How Did You Hear About Us?