Moving Forward Application
Your Information:
Full Name
*
First Name
Last Name
Date of Birth
*
Age
*
Email
example@example.com
Best Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Gender
*
Male
Female
Veteran of the U.S. Military Services?
Yes
No
Branch of Military
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Are You Being Referred By An Agency? (CYFD, Court Compliance, Hospital, Detox, etc)
Yes
No
Referral Source
*
Please Select
Self
Family/Friends
Legal System
Other
Describe Relationship to Referring Source (Unless Self)
*
Referring Source Requirement
*
Voluntary
Court Ordered
Date Available to Start Treatment
*
-
Month
-
Day
Year
Date
Date Of Last Use:
*
How Often Do You Use?
*
Drug Of Choice?
*
Emergency Contact Info:
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Best Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Medical Insurance Info:
Do You Have Medical Insurance?
*
Yes
No
Insurance Company:
*
Criminal Offense History
Are You A Registered Sex Offender?
*
Yes
No
Have You Been Convicted Of A Felony?
*
Yes
No
Have You Been Convicted Of A Misdemeanor?
*
Yes
No
Do You Have An Pending Charges?
*
Yes
No
If any of the above are yes, please explain:
*
Medical History
Have You Experienced Any Seizure Activity Within The Last 12 Months?
*
Yes
No
Are You Pregnant?
*
Yes
No
Are you currently on any medications?
*
Yes
No
If Yes, Please Explain:
*
Do you have any current psychiatric and/or mental health medications?
*
Yes
No
If yes, please explain, including dose and frequency:
*
Tell us your story. What brings you to us?
*
Applicant Name:
*
First Name
Last Name
Application Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: