Admission Application

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Demographic Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Home Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Cell Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Other Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Birthdate {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Social Security No. {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Social Security No: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Gender Identity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Referred By {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Employment Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Education Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

School Name (if currently enrolled) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Current Contacts

Item {binding ItemNumber}

Relationship {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Provider Information

Item {binding ItemNumber}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Entitlements Information (Insurance)

Item {binding ItemNumber}

Alongside this application, please send us a copy of both sides of applicants insurance card.

Upload insurance card images {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding Name, mode=oneTime}

{binding Description}

Insurance Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Private Insurance Group ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Private Insurance Group ID {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Effective Start {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Expires {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Self Pay/Co Pay Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Entitlements Information (Income)

Item {binding ItemNumber}

Income Source {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

ID Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Effective {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Expires {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Payee?? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hospital Episodes and/or Mental Health and Addiction Treatment History

Item {binding ItemNumber}

Admission Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hospital/Facility {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Hospital/Facility Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Reason/Outcome {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Efficacy of past and current treatment {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Additional Psychiatric History Details {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Current Diagnosis Information

Item {binding ItemNumber}

Condition {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Onset Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Diagnosis Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Current Allergy Information

Item {binding ItemNumber}

Allergen {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Reaction {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Severity {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Status {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Onset Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Digital Record {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dietary Restrictions {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Medication Information

Item {binding ItemNumber}

Medication {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Start Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Strength {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Dosage {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Frequency {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Immunizations - Yes, I have had the following.

We encourage all guests to have had a tetanus shot within the last 5 years.

Tetanus {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date last given {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

TB {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date last given {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Alcohol and Substance Use Information

Alcohol Use: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Substance Use: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Tobacco Use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Date of last use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

I use {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Average Amount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

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}

Other compulsive behaviors {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If Other, please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Family History

Family History and Relationship, Parental/Familial Caretaker Obligations: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pertinent Family Medical, Mental Heath, and Substance Use History: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Developmental History and Status: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Social Support

Friendship/Social/Peer Support Relationships, Pets, Community Supports/Self Help Groups (AA, NA, SMART, NAMI, Peer Support, etc.): {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Religion/Spirituality and Cultural/Ethnic Information: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Legal Status and Legal Involvement History

Does Person Served have a Legal Guardian, Rep Payee or Conservatorship? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Is there a need for a Legal Guardian, Rep Payee or Conservatorship? If yes, please explain: {{ Cognito.resources["required-asterisk"] }} , { 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}

If there is a history or current involvement with the legal system, please explain: {{ Cognito.resources["required-asterisk"] }} , { 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 }

Does person wish to consider using complimentary health approaches and want help finding a provider? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

If yes, please describe: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Trauma History

Does this person report a history of trauma? {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Please explain: {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Person Served Strengths / Abilities / Resiliency

Personal Qualities: (Examples: open, friendly, engaging, motivated, loyal, resourceful, caring, thoughtful) {{ 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 }

Financial/Employment/Education: (Examples: graduated HS, attended college, currently working, hx of working, multiple work skills) Un {{ Cognito.resources["required-asterisk"] }} , { 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 }

Leisure/Recreational/Community Involvement: (Examples: sports, belongs to social group, attends the gym, volunteers for Red Cross) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Natural Supports: (Examples: family members, clergy, close friends, neighbors, advisors) {{ Cognito.resources["required-asterisk"] }} , { 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 }

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 }

Admission Application

Demographic Information

Current Contacts

Item {binding ItemNumber}

Provider Information

Item {binding ItemNumber}

Entitlements Information (Insurance)

Item {binding ItemNumber}

Entitlements Information (Income)

Item {binding ItemNumber}

Hospital Episodes and/or Mental Health and Addiction Treatment History

Item {binding ItemNumber}

Current Diagnosis Information

Item {binding ItemNumber}

Current Allergy Information

Item {binding ItemNumber}

Medication Information

Item {binding ItemNumber}

Immunizations - Yes, I have had the following.

Alcohol and Substance Use Information

Family History

Social Support

Legal Status and Legal Involvement History

Physical Health Summary

Trauma History

Person Served Strengths / Abilities / Resiliency

Admission Application

Demographic Information

Current Contacts

Item {binding ItemNumber}

Provider Information

Item {binding ItemNumber}

Entitlements Information (Insurance)

Item {binding ItemNumber}

Entitlements Information (Income)

Item {binding ItemNumber}

Hospital Episodes and/or Mental Health and Addiction Treatment History

Item {binding ItemNumber}

Current Diagnosis Information

Item {binding ItemNumber}

Current Allergy Information

Item {binding ItemNumber}

Medication Information

Item {binding ItemNumber}

Immunizations - Yes, I have had the following.

Alcohol and Substance Use Information

Family History

Social Support

Legal Status and Legal Involvement History

Physical Health Summary

Trauma History

Person Served Strengths / Abilities / Resiliency

Your progress has been saved.

Admission Application

Demographic Information

Current Contacts

Item {binding ItemNumber}

Provider Information

Item {binding ItemNumber}

Entitlements Information (Insurance)

Item {binding ItemNumber}

Entitlements Information (Income)

Item {binding ItemNumber}

Hospital Episodes and/or Mental Health and Addiction Treatment History

Item {binding ItemNumber}

Current Diagnosis Information

Item {binding ItemNumber}

Current Allergy Information

Item {binding ItemNumber}

Medication Information

Item {binding ItemNumber}

Immunizations - Yes, I have had the following.

Alcohol and Substance Use Information

Family History

Social Support

Legal Status and Legal Involvement History

Physical Health Summary

Trauma History

Person Served Strengths / Abilities / Resiliency