The Recovery House Application

Inpatient Treatment Services Application

Please complete this form to apply for inpatient treatment services. All information will be kept confidential.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Gender
Social Security Number
Veteran of the US Military
Do you have a stable Internet connection?
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Are you being referred by an agency?
See where the court compliance, hospital detox, etc.
Referring Source Requirement
Referral Source
Referring Source Contact Name

First NameLast Name
Referring Source Email
example@example.com
Referring Source Phone
Please enter a valid phone number.Format: (000) 000-0000.
Describe Relationship to Referring Source
Treatment Time Requested
New Intake or Re-admission
Date Available to Start Treatment

MonthDayYear
Date
Drugs of Choice
Date of Last Use

MonthDayYear
Date
How often do you use drugs of choice?
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Relationship
Emergency Contact Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Do you have medical insurance?
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Card ID Number
Group ID Number
Have you been or are you currently affiliated with any gang related activity?
Are you a registered sex offender?
Have you been convicted of a felony? If yes please explain
Have you been convicted of a misdemeanor?
Do you have any pending charges?
Signature and Date
What is the highest level of education you have completed?
Were you ever diagnosed with a learning disability?
Have you ever worked with a mental health provider?
Do you require an oxygen tank?
What is your current height and weight?
Last Visit Date to Primary Care Physician

MonthDayYear
Date
Have you ever been hospitalized? If yes please explain
Have you or are you being treated for any of the following?
Are you currently having symptoms related to any of the following?
Mental Health History
Do you have any mental health history diagnosis?
Reason for Seeking Inpatient Treatment
Please provide a brief medical history, including any current diagnoses or previous treatments
List any current medications, allergies or special needs
Should be Empty:

Inpatient Treatment Services Application