Request For Services

Application for Services

At Four Winds Behavioral Health, your privacy, dignity, and confidentiality are our highest priorities. All information submitted through this application is protected in accordance with HIPAA privacy and security regulations and is handled with the utmost care by our licensed and authorized staff. Your personal and health information is kept strictly confidential and used only for the purpose of evaluating services and coordinating appropriate care. We are committed to providing a safe, secure, and respectful process as you take this important step toward support and recovery.
Treatment Length
Type of Treatment
Name

First NameLast Name
Date of Birth
Social Security Number
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender
Veteran of the U.S. Military Services?
Do you have a stable Internet connection?
Referring Agency
Type of Intake
Are you being referred by an Agency? (Probation/Parole, Court Compliance, CYFD, etc.)
Agency Name
Contact Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Emergency Contact
Emergency Contact Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Relationship To You
Mother, Father, Brother, etc.
Emergency Contact Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Reason For Seeking Treatment
Drug(s) of choice:
Alcohol, Heroin, Methamphetamine, etc..
Date of Last Use

MonthDayYear
Date
Medical Insurance
Insurance Company Name
Blue Cross, Blue Shield, etc...
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance ID#
Group ID#
Criminal Offense History
Are you required to register as a sex offender?
If Yes, Please briefly explain
Have you been convicted of a felony?
If Yes, Please briefly explain
Have you been convicted of a misdemeanor?
If Yes, Please briefly explain
Do you currently have any pending charges?
If Yes, Please briefly explain
Have you or are you currently affiliated with any gang related activity?
Advanced Directives: (Check all that apply)
If you selected any of the selections above besides "None" please upload your paperwork below. ALL PAPERWORK REFERRING TO ADVANCED DIRECTIVIES MUST BE PROVIDED BEFORE APPLICATION WILL BE CONSIDERED

Cancelof
Medical History
Can you walk up and down stairs?
If no, please explain further
Are you diabetic? Do you require a special diet?
If yes to diabetic, please explain further
Do you currently have any major medical conditions?
If yes to major medical conditions, please explain further
Are you currently taking any medications?
If yes, please list the medications
Do you have any medication allergies and adverse reactions:
If yes to medication allergies, please explain further
Are you currently taking any psychiatric and/or medical medications?
If yes, please list the medications
Do you require an Oxygen tank?
Are you currently undergoing treatment for Hep-C
Have you or are you being treated for any of the following or are you currently having symptoms related to any of the following?
Please explain for each box you checked
Waiver To Release Application Status

I hereby authorize Four Winds Behavioral Health to release information regarding my application status. This authorization of release includes my application approval, estimated wait time, program acceptance, and intake for the purpose of aiding, collaboration and coordination of services. I authorize the following people to obtain my application status:
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Name

First NameLast Name
Relationship
Approved and Prohibited Items

It is the policy of FWBH that any prohibited items are not allowed on property at any time without written approval by the Executive Director. Prior to admission, a thorough search of your person and property will be conducted. Possession of any of the prohibited items may result in revocation of your application and intake status or offer. Possession of any prohibited items after the intake process is completed may result in your immediate discharge from the facility.
Approved Items Allowed Upon Intake:
- Pants/Jeans (up to 10)
- Sweat Pants (up to 10)
- Sweat Shirts (up to 10)
- Shirts (up to 10)
- Shoes (up to 3)
- Underwear (up to 10)
- Bras (up to 10)
- Socks (up to 10)
- Jackets/Light sweater
- Shower Shoes (1)
- Slippers (1)
- Cell Phone/Charger (1)
- Pajamas (up to 3)
- Robe (1)
- Belts (1)
- Hats (2)
- Towels (5)
- Washcloths (5)
- Undershirts (7)
- Musical Instruments Ex: Drums(1-2)
- Art Supplies
- 30-day supply of all current
  medication and medical supplies
Starter Kit (Must be brought within 36 Hours of Admission)
- Basic Hygiene Items-Shampoo, Conditioner,
  Soap, Guarded Razors, Shaving Cream, and
  Feminine hygiene products (Alcohol free)
- Toothpaste (1 tube 6 oz Min)
- Laundry Detergent (liquid and pods only)
- One carton of cigarettes
Non-Approved Items
- No Outside Food or Drinks
- Nail Polish/Polish Remover
- Hairspray (alcohol must be at least the 4th ingredient
  listed)
- Perfume/Cologne/Body Spray
- Coconut Oil
- Straight Razors
- Sharpie Markers
- Bandanas
- No Vapes
- No Chew or Dip/Tabacco products
- Room Freshener
- Hand Sanitizer (containing alcohol)
- Scissors
- Super Glue
- Glitter
- Mouthwash (Containing Alcohol)
- Hair dye
- DVD Players/Portable DVD Players
- Gaming Console, Fire TV Stick, Roku, Google TV
  or any media streaming devices (Must be authorized after admission)
- Sexually oriented materials and/or products
- Essential Oils
- Power Strips/3 way connectors
- Guns/Ammunition/Knives
- Pepper Spray
- Stun gun/Tasers
- Multi-use tools (Leatherman)
- Any item fashioned as a weapon
- Backpacks
- Steel-toe boots
- Combination locks
- Torches
- Rolling papers
- Speakers
- Removable Dental Jewelry
Authorization and Privacy Information

By signing below, I certify that all information is true and correct to the best of my knowledge. I authorize Four Winds Behavioral Health (FWBH) to use and disclose my health information to process this application and for treatment purposes. This includes contacting my Emergency Contact in a crisis and my Probation/Parole/Court Officer regarding my application and attendance, if necessary. "By submitting this application, I acknowledge that a staff member of this facility may be calling to ask follow up questions or communicate my application status. I authorize any staff member of the facility to call and identify themselves as calling from the facility to speak to me. "I understand that information released to these parties may be re-disclosed by them and is no longer protected by federal privacy rules. I may revoke this authorization in writing at any time. It will otherwise expire one year from today.
Should be Empty:

Application for Services

Referring Agency

Emergency Contact

Reason For Seeking Treatment

Medical Insurance

Criminal Offense History

Medical History

Waiver To Release Application Status

Approved and Prohibited Items

Non-Approved Items

Authorization and Privacy Information