Application

Contact Information

Name(required)
Email
Social Security #(required)
Street Address(required)
City, State Zip(required)
Phone Number(required)
Birthplace(required)
Height(required)
Weight(required)
Birth Date(required)
Sex(required)
Marital Status(required)
Sexual Orientation(required)
Who Referred You?

Emergency Contact Info

Emergency Contact
Relationship
Address
Phone

Emotional/Mental/Behaviorial Issues:

What, if any, are your concerns about your emotional/mental well being?
Please describe how you feel about yourself:
Have you ever suffered from depression or anxiety, or other serious mood disturbances? (Please describe)
Do you have any concerns about dealing with those emotions in therapy?
What do you do to help yourself relax?
How do you typically respond to stress?

Medical History:

Medical conditions that may interfere with residence:
Current or past medical / mental health problems / treatments / LIST ALL medications:
Personal Physician
Date of Last Physical
Suicide Thoughts or Attempts
Tobacco Use

Educational History:

Highest Grade Completed
Degree
GED
Extra Curricular Activities:

Employment History

List last three jobs, most recent first:
Job #1
Dates
Reason for Leaving
-------------------------------------------------
Job #2
Dates
Reason for Leaving
-------------------------------------------------
Job #3
Dates
Reason for Leaving
Effect of chemical dependency on employment:
Special talents or interests:

Military History:

Branch
Dates
Rank
Type of Discharge
Combat Duty

Ethnic / Cultural History:

Ethnic Origins
Influence & Importance

Spiritual / Religious History:

Religious background and beliefs:

Legal History:

Arrest Record
Charge #1
Date
Sentence
-------------------------------------------------
Charge #2
Date
Sentence
-------------------------------------------------
Charge #3
Date
Sentence
-------------------------------------------------
Probation or Parole Officer
Phone
Cases Pending

Special Needs in Residency:

Physical or mental health needs:
Other needs:

Alcohol & Drug History:

Describe all mood altering substances date of last use. (Include prescribed, street or over the counter):
Who in your family has history of chemical dependency:
Your previous treatment
What have been the consequences of chemical use in all areas of your life (family, health, legal, employment, financial etc.)

Additional Information:

Please list any additional information that may be helpful to aid in your recovery:

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