Once you have started this form you may choose to save it and return to filling it out at another time.
Simply click SAVE and the form will be emailed to the address you provided.
To resume, click the link in the email you receive and open the application on our website that you wish to complete. It will return you right where you left off.
Demographic Information
Name {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
Date of last use {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I use {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Average Amount {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Tobacco Use {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Date of last use {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
I use {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Average Amount {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Have you ever been told by a friend/family member or provider that you have a problem with alcohol or substances? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Other compulsive behaviors {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
Does Person Served have a Legal Guardian, Rep Payee or Conservatorship? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
Is there a need for a Legal Guardian, Rep Payee or Conservatorship?
If yes, please explain: {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
Does the person have a history of, or currently involved with the legal system (i.e.,
legal charges)? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{binding displayValue}
{ binding firstError.message }
If there is a history or current involvement with the legal system, please explain: {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
{ binding firstError.message }
Physical Health Summary
Does the person use complimentary health approaches (e.g. natural products, mindbody
practices, yoga)? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
Does person wish to consider using complimentary health approaches and want help finding a provider? {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
Living Situation: (Examples: has maintained long-term stable housing, gets along with living
companions) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
Financial/Employment/Education: (Examples: graduated HS, attended college, currently
working, hx of working, multiple work skills)
Un {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
Health: (Examples: consistent good health, exercises regularly, self-cares for health issues as
directed by physician, eats nutritional foods) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
Leisure/Recreational/Community Involvement: (Examples: sports, belongs to social group, attends the gym, volunteers for Red Cross) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
Natural Supports: (Examples: family members, clergy, close friends, neighbors, advisors) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
Spirituality/Culture/Religion: (Examples: enjoys religious services, participates in cultural
events, meets regularly with Rabbi) {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }
{ binding firstError.message }
If there are is any additional information that will help us in the admission process, please use the space below to write a brief narrative. {{ Cognito.resources["required-asterisk"] }}, { binding firstError.message }