PRE ADMISSION

Name

Email Address

Do you drink alcohol, use drugs, or both? If so what do you use?

How many times of the week do you indulge in usage, and how much do you use in one setting?

Have you been on a week or more binge in using drugs or alcohol currently? Have you been on a week or more binge in using drugs or alcohol currently? YES NO

Do you have any of the following physical conditions like blindness, deafness, or any other physical conditions like this the program should know about? Do you have any of the following physical conditions like blindness, deafness, or any other physical conditions like this the program should know about? YES NO

5. Do you have any serious mental/ medical illnesses that may need to be addressed and stabilized before drug and alcohol treatment is initiated ? 5. Do you have any serious mental/ medical illnesses that may need to be addressed and stabilized before drug and alcohol treatment is initiated ? YES NO

Are you court ordered to go to treatment? Are you court ordered to go to treatment? Yes No

unfortunately we don't offer the level of care that you will need, I hope that you find healing in your journey to live a healthier lifestyle