Admission Application

General Information
* Name
* Gender
* Date of Birth
Social Security Number (Optional)
Marital Status
Emergency Contact Name
Emergency Contact Address
Emergency Contact Phone Number
Emergency Contact Email Address
What is your relationship to this emergency contact?
Secondary Emergency Contact Name
Secondary Emergency Contact Address
Secondary Emergency Contact Phone Number
What is your relationship to this secondary emergency contact?
How did you hear about us?
If you found us via a Treatment Center, which one referred you?
In the event of a relapse, would you like us to take you to a detox center?
In the event of a relapse, would you like us to wait for a particular party to pick you up?
Primary Language
What are your hobbies?
Personal Information
* Address
* City
* State
* Zip
* E-mail Address
* Primary Telephone Number
* Preferred communication method
Portal Access
* Username
* Temporary Password
Recovery History
When was the last time you used drugs or alcohol?
Date of Sobriety
What are your drug(s) of choice?
What was the primary drug you were addicted to?
Length used?
Method of use?
Maximum daily use?
Additional drug used
Length used?
Additional drug used
Length used?
Overdoses?
Why is now the time? How serious are you about this?
Do you have a sponsor?
What was your longest period of sustained abstinence?
Are you currently enrolled in any PHP treatment services?
Are you currently enrolled in any IOP treatment services?
Employment Readiness
Do you have a valid form of photo identification, such as a driver's license?
Do you have a valid Social Security Card?
Do you have a valid Birth Certificate?
Are you currently recieving Social Security Benefits?
Are you currently recieving Disability Benefits?
Are you currently employed?
Please list all work/occupational skills related to your work history:
Total monthly net income
Spouse total monthly net income
Do you have any specific welfare needs you need assistance with (food stamps, food bank etc.)
Criminal Justice History
Have you ever been arrested?
Have you been convicted of a crime?
Have you ever been charged with: abuse or neglect of a child, disabled person or senior; abuse or harm to an animal; arson; forgery; identity theft?
Do you have any open court cases, warrants or active restraining orders?
Do you have any existing or outstanding court fees?
Medical History
Do you have any mental health disorders? (This includes, overdose, suicide attempts, nervous conditions, hospitalizations, etc.)
Are you currently engaged with any mental health service providers?
Have you ever tested positive for HIV?
Have you ever tested positive for Hepatitis C?
Have you ever tested positive for Tuberculosis?
Are you currently taking any prescribed medications?
List all schedule IV medications you are currently taking. (eg. Adderall, Ritalin, Vyvance, Codeine, Valium, Restoril, Robitussin AC, etc)
Please list all other medications you are currenty taking. (Including over the counter medications)
Are you allergic to any medications?
Do you any food or enviornmental (non-medication) allergies we should be aware of?
Do you have a Primary Care Physician
Do you feel you have any special needs? How should we treat?
Do you have any physical health conditions?
Insurance Information
Do you currently have insurance?
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