Intensive Admissions Form

Please fill out the form to the best of your ability to get started with our admissions team.

Our Admissions form has been divided into 3 easy to use sections. Please fill out the following three sections, Contact Information, Patient Information, and Patient History, to the best of your ability. The more information we receive, the better our Intensive Care Specialists will be able to help.

Step 1) Contact Information

* First Name: Last Name: * Email: * Phone 1: Phone 2: Best time to call: Please select one Morning Afternoon Evening

Street Address: Suite: City: State: Postal Code:

Step 2) Patient Information Click Here to continue to Step 2

Age: Relation to Client: Height: Weight: Faith/Beliefs: Insurance/Funding: Meidcare/Medicade:

Type of Intensive Treatment: Please select one Depression Anxiety Binge Eating Restricting (Anorexic) Bulimia (Purging) Sexual Abuse Other Trauma Grief/Loss Sexual Addiction Anger Issues Relationship Issues Alcohol/Drugs Gambling Internet Main Concerns: Comments:

Step 3) Patient History Click Here to continue to Step 3

Please check all that apply:

Weight loss or gain

Sleep Issues

Difficult Childhood

Past Suicide Attempts

Frequent thoughts of suicide currently

Self-Harming Behaviors

History of seizures and/or seizure disorder

Victim of physical assault

Victim of emotional abuse

Victim of sexual assault/abuse

Loss of parent or sibling

Fill out the following to the best of your knowledge:

Past Residential Centers (Places & Dates) Past Inpatient treatments (Places & Dates) Past day treatment (Places & Dates) What do you wish to accomplish in treatment?

Other Treatment (Places & Dates) Current medications/doses Medical History (Heart Issues, Diabetes, etc.)

Please check all that you can answer "Yes" to:

Do you use drugs or substances?

Do you consume alcohol?

Have you ever felt you should cut down on drinking?

Have people annoyed you by criticizing your drinking?

Have you ever felt bad or guilty about your drinking?

Have you drank in the morning to steady your nerves?

Are there any court cases pending?

Please check this box if you would like our Hope Newsletter

Enter the text below into the adjacent box and click submit:

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