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
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5
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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
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1932
1931
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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
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: