Admission Application

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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 }

{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}

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