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
MaleFemaleNon-binaryPrefer not to say
Social Security Number*
YesNo
YesNo
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
YesNo
Court ComplianceHospital DetoxOther
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
30 days60 days90 days
New IntakeRe-admission
Date Available to Start Treatment*

MonthDayYear
Date
Drugs of Choice
Date of Last Use

MonthDayYear
Date
DailyWeeklyMonthlyRarelyNever
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
YesNo
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Card ID Number
Group ID Number
YesNo
YesNo
Have you been convicted of a felony? If yes please explain
YesNo
YesNo
Signature and Date*
Less than High SchoolHigh School GraduateSome CollegeAssociate DegreeBachelor's DegreeGraduate Degree
YesNo
YesNo
YesNo
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
Mental HealthSubstance UseChronic IllnessOther
Mental HealthSubstance UseChronic IllnessOther
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