Intake Screening Form

How old are you?      

Where are you from?   City and State   

What's your drug of choice?   Drug of Choice (Please list all)   
(You must be detoxed from Alcohol and Benzos before coming to us)

Are you pregnant?      Please Select Yes No

How did you hear about us?            

Do you have any pending charges?    Please Select Yes No
If yes, what for?   Please list all pending charges       
What County is your pending charge in?   County and State (Please list all counties/states)   

Are you currently on probation?    Please Select Yes No
If so, what are you on probation for?   Please list all      
What county are you on probation in?   Please list all   
What is your Probation Officer's name?   PO Name(s)   
What is your Probation Officer's phone number?      Phone Number(s)      

Are you a registered sex offender?    Please Select Yes No    
(We do not allow registered sex offenders)

Are you currently prescribed any medications?    Please Select Yes No
If yes, please list all medications you are currently taking here.  (We do not allow any controlled substances or narcotics. We also do not allow Gabapentin or Effexor) List all medications here      

Have you had the Sublocade shot in the last 18 months?    Please Select Yes No

Are you disabled?    Please Select Yes No

Do you have a valid ID or driver's license?    Please Select Yes No
Do you have a Social Security card?    Please Select Yes No

What date are you wanting to come?   Date   

Are you interested in our 28-Day or 90-Day Program?     

Do you have the intake fee? (28-Day Program $1,750.00, 90-Day Program $1,000.00)    Please Select Yes No (If you do not have the intake fee, there may be treatment scholarships available)

If you are in need of a treatment scholarship, why do you feel you should be considered for one?       

Why are you seeking treatment? Tell us a little about your story.   Type a label