APPLICANT DETAILS
    APPLICATION DATE

    SUBSTANCE USE HISTORY

    Substances you used/abused (check all that apply – circle your primary substances):

    Alcohol
    Benzos (Xanax, Klonipin)
    Methamphetamines
    Opiates

    Cocaine
    LSD
    PCP
    Heroin

    Amphetamines
    K2 (Spice)
    Bath Salts
    Marijuana

    Ecstasy
    Other

    Please describe provider and program below:
    Provider Name
    Program Type

    (in-patient rehab, IOP, private counseling, hospitalization)

    City, State
    Year

    What 12-Step groups have you attended?

    AANACAOther

    I have a sponsor

    REFERRAL INFORMATION
    Referral Type:

    Self
    Sponsor

    Treatment Center
    Hospital

    Friend
    Family

    Healthcare Provider
    other

    PAROLE/PROBATION/WARRANT

    I am on parole/probation.

    I have a warrant for my arrest

    EMERGENCY CONTACT

    OCCUPATION

    I have a job.

    I go to school.

    MEDICAL INFORMATION
    Other than addiction, are you being treated for any other physical or mental conditions? YesNo

    If yes, please describe:

    Do you have the following? Hepatitis CHIV Positive/AIDS
    Are you receiving treatment? Yes No
    Are there other physical or mental conditions you are not receiving treatment for? YesNo

    If yes, please describe:

    If you are taking prescribed medications, please list the name, dosage, and purpose of each, below.

    Name

    Dosage

    Purpose

    Name

    Dosage

    Purpose

    Do you currently or have you in the past, engaged in the following behaviors (check all that apply)?

    Attempted Suicide

    Injuring Self (cutting, burning, etc.)

    Bulimia/Anorexia

    Kleptomania

    OTHER INFORMATION

    I have a vehicle

    I have medical insurance

    I have a primary care physician