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
Client Name*

First NameMiddle NameLast Name
Nickname(s)
Date of birth:
Gender assigned at birth*
Identifies as (pronouns):
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail
example@example.com
Phone Number*
Alt Phone Number
Race/Ethnicity
If you identify as Native American, what is your Tribal Affiliation?
Enrollment Number (if applicable):
Social Security Number
Sources of income (employment, SSI benefits, etc.):
Do you have a disability? If so, please explain:
Have you received recent substance use disorder treatment? If so, please specify where you received treatment and the dates of treatment:*
Referring Agency
Referring Agency Contact Name

First NameLast Name
Referring Agency Phone Number
Please enter a valid phone number.
Do you know anyone who is currently receiving services at or works for Nat-su Behavioral Health?*
What services are you seeking?*
What are your goals for treatment?*

Please fill out the sections of the chart that apply to your substance use history. *

	First Use/ Type	Last Used Date	Frequency
Alcohol
Marijuana
Methamphetamines (desoxyn, crystal meth, ice)
Cocaine (crack, coke, etc.)
Opioids (fentanyl, heroine, prescriptions, morphine)
Amphetamines (speed, prescriptions)
Hallucinogens (LSD, Psilocybin, Peyote, PCP, MDMA)
Inhalants (nitrous oxide, glue, paint thinners, or other volatile substances)
Benzodiazepines (Xanax, Ativan, Valium)
Other
Never used

Residential/IOP Treatment Application Form