Vibrant Life Behavioral Health

Name *

First NameLast Name

Phone Number*

Please enter a valid phone number.

Email

example@example.com

Address*

Street Address

Address Line 2

CityState

Zip Code

1. Do you have medicaid or health insurance currently?

YesNo

Please provide name of the health insurance

2. Are you currently taking any medications?

YesNo

List the medications

0/1000

3. Are you on probation or parole? If so please list the officer's name and contact information.

4. Do you have any upcoming court appearances? If so, what are the charges and what are the dates? What is your public defender or attorney's name and contact information?

5. Do you have means while you are in the program to cover the cost? If not, do you have any family, coworkers, friends or a church that would help cover the cost while you are in the program?

6. To the best of your knowledge, which of the following substances has the applicant used? Are they currently used and what is the frequency of use?

7. Have you been in any other treatment programs (including Teen Challenge)? Did you complete it or what was the reason for leaving?

8. What do you hope to get out of this program, and are you willing to do whatever it takes while you are in the program to help yourself get better?

9. What is your reason for seeking treatment today?

10. Can you give a brief description of the circumstances surrounding your decision to seek treatment.