Intake Application

Name
Date Of Birth

Address
Phone
Email
Preferred residential unit/location
Preferred commencement date

Detail Substance Abuse Issues

Treating Medical Practitioner:

Name
Address
Phone
Email

Other Treating Practitioner/s:

Name
Address
Phone
Email
Name
Address
Phone
Email

Personal History:

Treatment History
Marriage History
Name & ages of children
Closest family member/s names and contact details
Closest friend/s names and contact details
Employment History
Trauma History
Criminal History
Psychiatric History
Please indicate 6 or 12 month program & to whom invoice should be forwarded