Pre-Admission Application
Our pre-admission application is designed to determine a future client's eligibility to enter recovery at The Oaks.
Basic Information
Please provide basic information for the person seeking recovery.
I am completing this application on behalf of someone else:
*
Yes
No
Does the potential resident know you are submitting this application for treatment?
*
Yes
No
Name of Person Seeking Recovery
*
First Name
Last Name
Birthdate
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Relationship Status
*
Please Select
Single
Dating
Married
Divorced
Widowed
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Substance Abuse History
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
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Does drug addiction run in the applicant's family?
*
Please Select
Yes
No
Has the applicant received in-patient treatment before?
*
Please Select
Yes
No
Previous times in in-patient treatment
*
Previous In-Patient Treatment Stays
Rows
Facility Name
Admission Start Date
Admission End Date
Treatment
Treatment
Treatment
Treatment
Treatment
Has the applicant spent any time in sober living?
*
Please Select
Yes
No
Medical History
Does this person have any health or medical issues we should know about?
*
Please Select
Yes
No
Please list any professionally diagnosed conditions, physical or mental:
Has this person been diagnosed with a mental health condition?
*
Please Select
Yes
No
Please describe the applicant's mental health diagnosis. Include month/year of diagnosis.
*
Is this person currently in therapy?
*
Please Select
Yes
No
Is this person currently taking medication for any medical condition?
*
Please Select
Yes
No
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.
Rows
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.
Legal Information
Has the applicant ever been arrested?
*
Please Select
Yes
No
Are there any current or pending legal matters to consider (probation, parole, upcoming court dates, etc.)
*
Please Select
Yes
No
Do you have any pending court dates within the next 90 days that could interfere with your stay here at STXRF?
*
Please Select
Yes
No
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:
Acknowledgment
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.
SUBMIT
SUBMIT
Should be Empty: