Admissions Application
Name
First Name
Last Name
Move-in date preferred
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Ok to leave a message?
yes
no
Date of birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Gender
Female
Male
Other
Race/Ethnicity
Asian/Pacific Islander
Black/African American
Biracial
Caucasian
Hispanic/Latino
Other
Employment
Full time
Part time
Student
Disabled
Unemployed
Main source of income/support
Do you have children? If yes, how many and who do they live with?
What is your highest level of completed education?
Substance Use Information
Are you currently using substances?
Yes
No (If not currently using please fill out the information below with previous substance use history)
What is your substance of concern/drug of choice?
How often did you use? (multiple times a day, daily, every other day, rarely)
How much did you use? (points, grams, or best estimate)
How did you use the substance?
IV
Nasal/Snort
Smoke
Oral
Other
Date of last use
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
What substances you are currently using?
How often do you use? (multiple times a day, daily, every other day, rarely)
How much do you use? (points, grams, or best estimate)
How do you use the substance?
IV
Nasal/Snort
Smoke
Oral
Other
Date of last use
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Are you using more than one substance?
Yes
No
What substances you are currently using?
How often do you use? (multiple times a day, daily, every other day, rarely)
How much do you use? (points, grams, or best estimate)
How do you use the substance?
IV
Nasal/Snort
Smoke
Oral
Other
Date of last use
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Are you in need of detox?
yes
no
Have you ever overdosed? if yes, when?
Do you have any current/ongoing medical conditions? (high blood pressure, heart concerns, diabetes, cancer, seizure disorders, nerve pain, HIV/AIDS, vision or hearing impairments?)
Are you currently pregnant?
Yes
No
Do you have any mental health diagnosis? (PTSD, anxiety, depression, bipolar, schizophrenia, BPD, etm)
What medications are you currently taking?
Have you ever had a period of abstinence or recovery? How long?
Have you been to a sober living, detox, or a mental health facility before? If so, where and what was the outcome?
Have you ever been discharged from a program? If so, explain the situation in detail.
Have you ever been arrested? If so, list the years and charges
Are you required to register as a sex offender?
yes
no
Are you currently on probation/parole?
yes
no
Which county/counties?
Do you have any pending charges?
yes
no
If so, what are they?
Do you have any known warrants for your arrest?
yes
no
If so, what county/counties?
Are you mandated to complete a residential treatment program?
Yes
No
What are you recovery goals? What has brought you to seek treatment now?
Who is supportive of your recovery?
Emergency Contact
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Disclaimer of application processing
All information/health data received in this application is considered identifying and confidential (PHI), protected under HIPPA (title 42 CFR part 2), and will not be released to any agency or persons without the written consent of the facility and is not able to accept applicants that are determined to require higher, more intensive mental health and/or addiction treatment services. Applicants with reported history of severe persistent mental health diagnoses may be required to provide documentation of active mental health care and clinical management as part of the application review process. Blackbird Place maintains the authority to decline any applicant on the basis of client safety, wellbeing, and access to alternative, appropriate care. Referrals for higher levels of treatment will be offered to declined applicants.
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