Intake

Sign-up For Drug & Alcohol Rehabilitation

Fill out the screening form below to start the intake process.

Full Name *

Phone *

Email Address *

Date of Birth *

Month

Day

Year

Do you have insurance? *YesNo

If yes, please provide Member ID number:

Substance: *

How long have you been clean/sober? *

Do you have a mental health diagnosis from a doctor? *YesNo

SchizophreniaBipolar DisorderDepressionAnxiety DisorderPTSD

Do you have any history of suicidal ideations or attempts? If so, give a brief description:

Have you had any recent auditory or visual hallucinations? If so, give a brief description:

Are you currently receiving any MATs (Medication-Assisted Treatment)? *YesNo

If yes, please list all medications:

Are you a diabetic?YesNo

If yes, Type I or II:

Do you have any mobility issues (walking, stairs, bunkbeds) or do you have trouble sitting for long periods of time?YesNo

If yes, explain:

Do you have asthma?YesNo

If yes, list what medications (if any) you take:

Do you have any history of seizures or a seizure disorder?YesNo

If yes, explain:

Any other medical concerns (or pregnant and if so how far along)?

Have you ever been a registered sex offender or charged with a sexual offense:YesNo

Currently on probation or parole?YesNo

If yes, provide probation/parole officer:

Currently incarcerated?YesNo

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