Form
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail
*
Confirmation Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Marital Status
*
Single
Married
Divorced
Widowed
Prefer not to say
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Are you currently in treatment?
*
Yes
No
Current Treatment Provider
Provider name and level of care.
Treatment start date.
*
-
Month
-
Day
Year
Date
Treatment end date.
*
-
Month
-
Day
Year
Date
Total number of inpatient stays.
*
1
2
3
4
5+
Total number of outpatient stays.
*
1
2
3
4
5+
Total number of detox admissions.
*
1
2
3
4
5+
Total number of extended care/sober living admissions.
*
1
2
3
4
5+
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Current case manager?
if none, type N/A
Best method of contact?
*
Phone
E-mail
Give us a brief history of your substance abuse.
*
Please type in all current medications.
*
Type in all mental health diagnoses.
*
How do you intend on initially affording to stay at Tidewater?
*
Parents/Family Assistance
Government Assistance
Savings
Other
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Do you have any current legal issues?
*
Yes
No
If yes, please type in all previous legal criminal convictions and upcoming court dates.
Expected move-in date?
*
-
Month
-
Day
Year
Date
Current means of transportation?
*
In your own words why do you want to stay at Tidewater Residences?
*
Submit
Should be Empty: