• Rehab Application

  • *Your application is completely confidential.  All information is stored in a secure environment and used only for purposes related to your admission and recovery program.

     

  • Your Information:

  • Format: (000) 000-0000.
  • Gender*
  • Veteran of the U.S. Military Services?*
  • Do You Have A Stable Internet Connection?*
  • Are You Being Referred By An Agency? (CYFD, Court Compliance, Hospital, Detox, etc)*
  • Referring Source Requirement*
  • Select All That Apply:*
  • Date Available to Start Treatment*
     - -
  • Format: (000) 000-0000.

  • Emergency Contact Info:

  • Format: (000) 000-0000.

  • Medical Insurance Info:

  • Do You Have Medical Insurance?*
  • Format: (000) 000-0000.

  • Criminal Offense History

  • Have You Been Or Are You Currently Affiliated With Any Gang Related Activity?*
  • Are You A Registered Sex Offender?*
  • Have You Been Convicted Of A Felony?*
  • Have You Been Convicted Of A Misdemeanor?*
  • Do You Have An Pending Charges?*
  • Clear
  • Date*
     - -

  • Medical History

  • Have You Experienced Any Seizure Activity Within The Last 12 Months?*
  • Are You Pregnant?*
  • Do You Require Any Special Diets?*
  • Do you currently have any medical conditions which require special care?*
  • Are you currently on any medications?*
  • Do you have any allergies and adverse reactions:*
  • Do you have any current psychiatric and/or mental health medications?*
  • Were you ever diagnosed with a learning disability?*
  • Have you ever worked with a mental health provider (psychiatrist, psychologist, therapist)?*
  • Do You Require An Oxygen Tank?*
  • Have You Ever Been Hospitalized?*
  • Have you or are you being treated for any of the following? Are you currently having symptoms related to any of the following? (Check all that apply)*

  • Mental Health History

  • Personal mental health history (Check all that apply):*

  • Waiver To Release Application Status

  • Application Date*
     - -

  • Authorization:

    I hereby authorize to release information regarding my application status, estimated wait time, program acceptance, and intake for the purpose of collaboration and coordination of services to any affiliated facilities, my attorney, caseworker, Parole/Probation officer, Counselor, and family.  I also authorize the following people to obtain my application status:
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Disclosures:

    I understand that related Rehab Organization cannot guarantee that the recipient will not disclose my application status to a third party. I understand that I can revoke my waiver at any time and for any reason. I understand that my Authorization will automatically expire one year from the date of my signature unless I request it be revoked earlier (see below). IF YOU ARRIVE AT YOUR CHECK-IN WITH ALCOHOL IN YOUR SYSTEM, YOU MAY BE TURNED AWAY. A COVID TEST WILL BE ADMINISTERED UPON ARRIVAL. A NEGATIVE COVID TEST RESULT WILL BE REQUIRED FOR ENTRY. By submitting this application, I approve Rehab Organization and their affiliated facilities to disclose their company name when attempting to contact me
  • Clear
  • Date*
     - -

  • Transition Planning

    Rehab Organization is an Intensive Outpatient Treatment center providing evidence based and person-centered drug and alcohol rehabilitation treatment. Our evidence-based treatment program promotes a long term sobriety lifestyle which includes transition planning as soon as treatment is initiated. For this reason, Rehab Organization request that clients identify a safe discharge destination and a person who is supportive of his/her recovery.
  • Format: (000) 000-0000.
  • If no discharge destination has been identified, I authorize Rehab Organization to provide transportation or make arrangements for transportation to a mutually agreed upon location regardless of the reason for my discharge. I understand that I must notify Rehab Organization if my discharge destination changes.
  • Clear
  • Date*
     - -

  • Acknowledgment of Approved and Prohibited Items:

    It is Rehab Organization policy that any prohibited items are not allowed on property at any time without prior written approval from the Executive Director. Prior to admission, a thorough search of your person and property will be conducted. Possession of any of the prohibited items may result in revocation of your application and/or admission status. Possession of any prohibited items after the admission process is completed may result in your immediate discharge from the facility.

  • Approved Items Allowed Upon Admission:

    • Pants/Jeans (up to 10)
    • Sweat Pants (up to 10)
    • Sweat Shirts (up to 10)
    • Shirts (up to 10)
    • Shoes (up to 3)
    • Underwear (up to 10)
    • Bras (up to 10)
    • Jackets/Light sweater (up to 3)
    • Pajamas (up to 3)
    • Shower Shoes (1) / Slippers (1)
    • Cell Phones (1)
    • Robe (1)
    • Belts (1)
    • Hats (2)
    • Towels (5)
    • Washcloths (5)
    • Undershirts (7)
    • Musical Instruments Ex: Drums (1-2)
    • Art Supplies (alcohol free)
    • Face Masks
    • 30-day supply of all current medication and medical supplies

  • Starter Kit:

    • Basic Hygiene Items-Shampoo, Conditioner, Soap, Guarded Razors, Shaving Cream, and Feminine hygiene products (alcohol must not be listed in the first 3 ingredients)
    • One carton of cigarettes

  • Non-Approved Items:

    • Outside Food or Drinks
    • Nail Polish/Nail Polish Remover
    • Hair Dye
    • Hairspray (if alcohol is in the first 3 ingredients listed)
    • Perfume (if alcohol is in the first 3 ingredients listed)
    • Coconut Oil
    • Straight Razors
    • Sharpie Markers
    • Bandanas
    • DVD Players/Portable DVD Players
    • Fire Stick, Roku, Google TV or any media streaming devices
    • Sexually oriented materials and/or products
    • Essential Oils
    • Power Strips/3 way connectors
    • Guns/Ammunition/Knives
    • Pepper Spray
    • Stun gun/Tasers
    • Multi-use tools (Leatherman)
    • Any item fashioned as a weapon
    • Gaming Systems
  • Clear
  • Date*
     - -
  • Should be Empty:
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