Application

Contact Information

Emergency Contact Info

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:

Employment History

Military History:

Ethnic / Cultural History:

Spiritual / Religious History:

Legal History:

Special Needs in Residency:

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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