Pre-Admission Application

I am completing this application on behalf of someone else:*

YesNo

Does the potential resident know you are submitting this application for treatment?*

YesNo

Name of Person Seeking Recovery*

First NameLast Name

Birthdate*

MonthDayYear

Relationship Status*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

What Drug(s) Are You Currently Using? Please include alcohol, marijuana, or prescription drugs.*

Please provide the quantity and frequency of your usage for each. *

Date of Last Use*

Date

Does drug addiction run in the applicant's family? *

Has the applicant received in-patient treatment before?*

Previous times in in-patient treatment*

Previous In-Patient Treatment Stays

	Facility Name	Admission Start Date	Admission End Date
Treatment
Treatment
Treatment
Treatment
Treatment

Has the applicant spent any time in sober living?*

Does this person have any health or medical issues we should know about?*

Please list any professionally diagnosed conditions, physical or mental:

Has this person been diagnosed with a mental health condition? *

Please describe the applicant's mental health diagnosis. Include month/year of diagnosis. *

Is this person currently in therapy?*

Is this person currently taking medication for any medical condition?*

Please list any medications the applicant is currently taken along with the conditions they are used to treat, the daily dosage/frequency and when you started the medication.

	Medication Name	Condition Treated	Dosage	Frequency	Start Date
Medication
Medication
Medication
Medication
Medication

Please describe any medical issues that may play a role in a treatment environment.

Has the applicant ever been arrested?*

Are there any current or pending legal matters to consider (probation, parole, upcoming court dates, etc.)*

Do you have any pending court dates within the next 90 days that could interfere with your stay here at STXRF?*

Please provide the dates of any known court dates.*

Please list any law enforcement encounters NOT under the influence of drugs or alcohol:

Please list any law enforcement encounters under the influence of drugs or alcohol:

How long is the applicant willing to commit to a recovery program?*

I acknowledge that the above-provided information is correct to the best of my knowledge. I understand that a submitted application does not mean immediate acceptance into the program.

Pre-Admission Application

Basic Information

Substance Abuse History

Medical History

Legal Information

Acknowledgment