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
*
90 Days
6 Months Treatment
Type of Treatment
*
In-House Treatment (Intensive Outpatient)
Off-Site (Outpatient)
Name
*
First Name
Last 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
City
State / Province
Postal / Zip Code
Gender
*
Male
Female
Other
Veteran of the U.S. Military Services?
*
Yes
No
Do you have a stable Internet connection?
*
Yes
No
Referring Agency
Type of Intake
*
Voluntary
New Intake
Court Ordered
Re-admission
Are you being referred by an Agency? (Probation/Parole, Court Compliance, CYFD, etc.)
*
Yes
No
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 Name
Last 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
City
State / Province
Postal / Zip Code
Reason For Seeking Treatment
Drug(s) of choice:
*
Alcohol, Heroin, Methamphetamine, etc..
Date of Last Use
*
-
Month
-
Day
Year
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?
*
Yes
No
If Yes, Please briefly explain
Have you been convicted of a felony?
*
Yes
No
If Yes, Please briefly explain
Have you been convicted of a misdemeanor?
*
Yes
No
If Yes, Please briefly explain
Do you currently have any pending charges?
*
Yes
No
If Yes, Please briefly explain
Have you or are you currently affiliated with any gang related activity?
*
Yes
No
Advanced Directives: (Check all that apply)
*
Living Will
Medical Power of Attorney
Durable Power of Attorney for Healthcare
Psychiatric Advance Directive
Guardianship
Other
None
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
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Medical History
Can you walk up and down stairs?
*
Yes
No
If no, please explain further
*
Are you diabetic? Do you require a special diet?
*
Yes
No
If yes to diabetic, please explain further
*
Do you currently have any major medical conditions?
*
Yes
No
N/A
If yes to major medical conditions, please explain further
*
Are you currently taking any medications?
*
Yes
No
If yes, please list the medications
*
Do you have any medication allergies and adverse reactions:
*
Yes
No
If yes to medication allergies, please explain further
*
Are you currently taking any psychiatric and/or medical medications?
*
Yes
No
If yes, please list the medications
*
Do you require an Oxygen tank?
*
Yes
No
Are you currently undergoing treatment for Hep-C
*
Yes
No
Have you or are you being treated for any of the following or are you currently having symptoms related to any of the following?
*
Asthma
Dizziness
Urinary Problems
Vision Problems / Loss
Hearing loss or ringing in ears
Allergies, seasonal or other
Bleeding problems/easy bruising
Heart conditions
Migraines, headaches
Digestive problems
Stroke
Thyroid problems
Diabetes
Cancer
Sleep apnea
Gastric reflux or ulcers
Pancreatic or gall bladder disease
Head trauma
Sexual dysfunction
HIV
Hepatitis
Heart attack
High or Low Blood Pressure
Other
None
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 Name
Last Name
Relationship
*
Name
First Name
Last Name
Relationship
Name
First Name
Last Name
Relationship
Name
First Name
Last 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.
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