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Intensive Admissions Form

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

* = Required Fields
Contact Information
Your Name: *
 Relation to Client: *
Client Name: *
 Age: *
 Height: *
 Weight: *
Street Address: *
 Suite Number:
City: *
 State: *
 Zip Code: *
Home Phone: *
 Cell Phone: *
 Work Phone:
Email: *
 Faith/Beliefs:
Medicare/Medicade: Insurance/Funding: Want our Hope Newsletter?
Patient Information
Type of Intensive Treatment: *
Main Concerns: *
Weight loss or gain
Self-harming behaviors (Cutting, Picking, Hitting, Etc.)
Past suicide attempts
Frequent thoughts of suicide currently
Sleep Issues
History of seizures and/or seizure disorder
Victim of physical assault
Victim of emotional abuse
Victim of sexual assault/abuse
Difficult childhood
Loss of parent or sibling
Past residential centers (Places & Dates): *
 Past inpatient treatments (Places & Dates): *
Past day treatment (Places & Dates): *
 Other treatment (Places & Dates): *
Current medications/doses: *
 Medical history (Heart Issues, Diabetes, etc.): *
Do you use drugs or substances?
Do you consume alcohol?
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticizing your drinking?
Have you ever felt bad or guilty about your drinking?
Have you had a drink in the morning to steady your nerves or get rid of a hangover?
Are there any court cases pending?
What would you like to accomplish in treatment? *
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