Please enable JavaScript in your browser to complete this form. - Step 1 of 25Name *FirstLastAddressAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNextWhat are the main reasons you are seeking treatment? *PreviousNextWhere are you completing this form? *HomeHospitalResidential ProgramOtherPreviousNextWhere do you reside? *On ownSober LivingFamily members homeOtherWho do you reside with? *SelfImmediate FamilyExtended FamilyFriendsRoommateUnhousedOtherPreviousNextAre you currently enrolled in a treatment center? *YesNoName of current treatment center *What level of care are you currently in? *RTCPHPIOPPreviousNextDo you have any history of trauma? (Emotional, Sexual, or Physical) *YesNoCan you further elaborate on your reported history of trauma? (Emotional, sexual, physical) *PreviousNextDo you have any history of being sexually or financially exploited? *YesNoPlease ExplainPreviousNextDo you have a history of Suicide Attempts? *YesNoHow many SA have you had in your lifetime?When was your last Suicide Attempt?What was the result in your last SA (example, hospitalization, ICU, etc.) PreviousNextHave you ever put yourself or someone else in harms way as a result of your mental health symptoms? *YesNoPlease explain: *PreviousNextAre you currently under the care of a physician for pain management? *YesNoPreviousNextDo you have any history of substance abuse? (Drugs or Alcohol) *YesNoLast date of use and what substance or Drug of choice? *Please explain in more detail: *Do you have a history of overdosing? *YesNoPlease describe when this occured, the substances used, and what happened after *Are you currently engaged in AA/NA or other sober support networks? *YesNoHave there been negative consequences due to your substance use? *YesNoPlease explain in a bit more detail *PreviousNextAre you currently experiencing any withdrawal symptoms? *YesNoPlease select any current withdrawal symptoms you are experiencing.NauseaTremorsBodyAchesRestless LegsExcessive YawningRunny NoseDiarrheaAbdominal CrampsVomitingSweatsChillsAgitationIncreased AppetiteConstipationPoor AppetiteGI ComplaintsDizzinessRestlessnessHeadachesAnxiosnessUnsteady GaitHypersensitivity to lightHypersensitivity to NoiseMusic/Body achesOther - Not ListedAdditional Symptoms not listed? *PreviousNextAre you open to trying anti craving medications? *YesNoDo you have a history of using MAT/anti-craving medications? *YesNoHow long were you on this medication and when were you prescribed? When did you stop taking this medication? *PreviousNextHave you been hospitalized in the past year? *YesNoWhat are the dates of your hospitalization? *Was your visit voluntary or involuntary? *VoluntaryInvoluntaryWhat was the name of the hospital, the reason for the visit, & the outcome? *PreviousNextAre you currently working with any outpatient provider (Psychiatrist, psychologist, therapist, etc.) *YesNoName of the provider *How long have you been working with this provider? *PreviousNextAre you currently taking any prescribed medications? *YesNoWhat medications are you currently taking, how many times per day, and what dosage? *Will you need us to provide these medications?YesNoPreviousNextDo you have any history of eating disorders? *YesNoPlease briefly describe what eating disorders you are/were struggling with? *Were the eating disorders ever diagnosed by a physician? *YesNoPreviousNextDo you have any active diagnosis for mental health, eating disorders, or others? *YesNoWhat were the diagnosis, what year were you diagnosed, & who was the diagnosing physician? *PreviousNextWill you need assistance with Disability, FMLA, SSI? *YesNoPreviousNextAre you currently employed? *YesNoJob position type? *Full timePart timeWhat is your current work schedule? *How long have you been employed and in what position? *Are you at risk for losing employment? *YesNoExplain why? *PreviousNextAre you at least 18 years of age? *YesNoWhat is your highest level of education? *Are you currently enrolled as a student? *YesNoAny issues with school? *YesNoPlease describe *Have you ever been placed on academic suspension or expelled? *YesNoDetails (Incident that resulted in suspension or expulsion) *Duration (How long did this last, is it still ongoing)? *Onset (When did this occur) *What grade are you in? *Who is your guardian? *PreviousNextAre you currently in any learning assistance programs? (IEP 504, etc...) *YesNoPreviousNextDo you require technology needs? Examples: Hearing Aids Visual Aids Physical Other *YesNoList below *PreviousNextDo you require assistance to communicate, read, or write in English? *YesNoPreviousNextDo you have the means and ability to complete a Telehealth program? *YesNoSubmit