Nat-su Behavioral Health Treatment Application

  • Residential/IOP Treatment Application Form

  • Fill out the form carefully to be considered for admission in to Residential Treatment or Intensive Outpatient. If you’re not looking for RTC/IOP services but want to apply for therapy, please click the link below to access our Therapy Application: Outpatient Counseling Services

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Legal Information

  • Are you on Parole/Probation*
  • Is your treatment a condition of Parole/Probation?
  • Are you a Registered Sex Offender?*
  • Any active Restraining Orders against you?*
  • Are you a convicted Felon?*
  • Do you have any current outstanding legal charges?*
  • Do you have any other past legal issues?*
  • Format: (000) 000-0000.
  • Are you currently incarcerated?*
  • Do you have an open case with DCFS?*

  • Detox Services History

  • Have you recently been treated in a detox program in the last 14 days?*
  • Will you require MAT (Medicated Assisted Treatment) services?*
  • If yes, which MAT option will you require? (Please note that Methadone is not available through our program )
  • Have you ever received MAT services?*

  • Medical Information

  • Are you on any prescribed medication?*
  • Do you have any food allergies?*
  • Do you have any medication allergies?*
  • Do you have any environmental allergies?*
  • Do you have allergies to sage, cedar, wheatgrass, or corn pollen?*
  • Are you experiencing any of the following health conditions? (Select all that apply)*
  • Do you have any current illness or treatment that would interfere with full participation in residential treatment?*
  • Are you up to date with your immunizations including vaccinations? (COIVD-19 is optional, all other vaccines are required).*

  • Substance Abuse History 

  • Rows

  • Mental Health

  • Were you referred by a Mental Health agency?*
  • If yes, do you have a treatment plan?
  • Are you currently feeling suicidal?*
  • If yes, do you have a plan?

  • If you are feeling unsafe or having thoughts of suicide, please reach out for help. You can call the suicide hotline at 988, dial 911, or get in touch with someone you trust right away. Your well-being is important, and support is available to help you through difficult times.
     
     
     

  • Have you attempted suicide in the past?*
  • Are you feeling angry enough that you want to hurt or kill someone?*
  • Are you hearing or seeing things that others don’t hear and see?*

  • Insurance Information

  • Note: Our facility is a Medicaid only facility. We do not accept any other insurance. The only exception is if you are an enrolled Tribal Member. 

    If you believe you are eligible for Utah Medicaid, but are not currently enrolled, follow the link below to start the Medicaid application process:   https://medicaid.utah.gov/apply-medicaid/

    If you have further questions please reach out to our admissions team. 

    Phone: 435-714-7376 

  • Do you have Medicaid Health Insurance?*

  • Required Documentation

  • Please email the following applicable documentation:

    • Medication Information:
      • Medication List
      • Proof of Vaccines
      • Medical History
      • Medical information regarding any current conditons
    • Recent Mental Health, Detox, and/or Substance use disorder documentation including:
      • Clinic Notes
      • Biopsychosocial
      • ASAM
      • Treatment Plan
      • Discharge paperwork
    • Attorney, Parole, and/or DCFS Paperwork

    Please email all necessary documents to admissions@natsuhealth.com. 

     

     

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