Screener

Freshly Renewed Transitional Application

Please complete the form in detail to help us serve you better. Please allow 24-48 hours for our team to complete the review process.
Which program are you applying to*

PHP/IOPOutpatient
How did you hear about our treatment center? (Referred by)*
Name*

First NameLast Name
Email*
example@example.com
Date of Birth (MM/DD/YY) *

MonthDayYear
Phone Number*
Please enter a valid phone number.
Race*

WhiteBlack or African AmericanAsianAmerican Indian or Alaska NativeNative Hawaiian or Other Pacific Islander
Are you Latino or Hispanic?*

YesNo
Gender Identity (select all that apply) *

WomanManTransgenderNon-binary/non-conformingPrefer not to respond
Is your gender the same as the sex you were registered at birth? *

YesNo
Please write gender below*
Marital Status*

SingleMarriedDivorcedSeparatedPrefer not to say
Which medical insurance provider do you use? (e.g., Blue Cross Blue Shield, UnitedHealthcare, Aetna) *
Are you employed?*

- YES- NO
Are you pregnant?*

- YES- NO- N/A
Emergency Contact Name*
Emergency Contact Phone Number*
Please enter a valid phone number.
Do you have work restrictions?*

YesNo
Are you currently on probation or parole?*

YesNo
If you are currently under probation or parole supervision, please provide the name of your probation or parole officer and the county of supervision. *
Have you ever been convicted of a violent crime?*

YesNo
Please provide details.*
Have you ever been convicted of a sex offense?*

YesNo
Please provide details.*
Please select all substances you have used: *

AlcoholTHC (Marijuana)Cocaine/CrackHeroinPrescription Opioids (Oxycodone, Fentanyl, Hydrocodone, Methadone)MethamphetamineHallucinogens (LSD, Mushrooms, etc.)Ecstasy/MDMAPrescription Stimulants (Adderall, Ritalin, etc.)Benzodiazepines (Xanax, Valium, etc.)InhalantsTranq (Xylazine)Synthetic (Cannabis, Opiates)
Please provide the date of your last use of alcohol.*

MonthDayYear
Please provide the date of your last use of THC (Marjiuana).*

MonthDayYear
Date
Please provide the date of your last use of cocaine.*

MonthDayYear
Date
Please provide the date of your last use of heroin.*

MonthDayYear
Date
Please provide the date of your last use of prescription opioids.*

MonthDayYear
Date
Please provide the date of your last use of methamphetamine.*

MonthDayYear
Date
Please provide the date of your last use of hallucinogens (LSD, Mushrooms, etc.).*

MonthDayYear
Date
Please provide the date of your last use of ecstasy/MDMA.*

MonthDayYear
Date
Please provide the date of your last use of prescription Stimulants (Adderall, Ritalin, etc.).*

MonthDayYear
Date
Please provide the date of your last use of benzodiazepines (Xanax, Valium, etc.).*

MonthDayYear
Date
Please provide the date of your last use of inhalants.*

MonthDayYear
Date
Please provide the date of your last use of tranq (Xylazine).*

MonthDayYear
Date
Please provide the date of your last use of synthetic (Cannabis, Opiates).*

MonthDayYear
Date
Are you currently enrolled in a Medication-Assisted Treatment (MAT) program?*

- YES- NO
Have you ever had NARCAN (naloxone) administered to you?*

- YES- NO
Do you have any Mental/Behavioral health diagnosis or concerns?*

YesNo
Please provide details.*
Do you have any medical health conditions?*

YesNo
Please provide details.*
Please list all medications you are currently taking, including the dosage and frequency. If you are not taking any, please enter 'None.' *
Are you currently at a Treatment Facility?*

YesNo
Expected Discharge Date

MonthDayYear
Have you previously received treatment at our center?*

YesNo
What year did you receive treatment at our center?*
Is there anything else you would like us to know about you? (Feel free to share any additional information you believe is important.)
File Upload (Initial Psychiatric Evaluation, BPS, Med List)

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Freshly Renewed Transitional Application