Apply Now Please fill out this form to the best of your ability, and our team will reach out to get started with you! Demographics Pronouns: Name: Address 1: Mobile #: Legal Name: Address 2: Home #: Alias: City: Ethnicity/Race: State: DOB: Language: Postal: SSNo: Religion: Country: Email: Other Information Are you currently employed? yesNo Have you been previously diagnosed? yesNo Is your job at risk? yesNo Do you need assistance with FMLA Paperwork? yesNo What led to you seeking treatment at this time? Willingness for treatment? yesNo Substance Use History Substance of Choice: Used last 30 days: YesNo Method of Use: Quantity: Last use: Age first used: Years of Use: Previous Treatments Location: Duration: Level Of Care: Response/ Sobriety Length: Location: Duration: Level Of Care: Response/ Sobriety Length: Consequences of Use - BPSA Precipitating Event: Do you find that it takes more or less alcohol or drugs to get the same effect as it once did? MoreLessNeither Have you ever had a blackout? yesNo Have you ever tried to hide your substance use from others? yesNo Have you ever tried to cut down or stop your substance use? yesNo Do you feel you have a problem with substances? yesNo Have you ever driven while under them influence of substances? yesNo As a result of using substances have you ever neglected: FamilySchoolWorkOther Have you ever lost friends or relationships because of substance use? yesNo Has anyone ever said they were concerned about your substance use? yesNo Have you decreased your social/recreation activities because of substances? yesNo Have you ever felt bad or guilty about your substance use? yesNo What negative consequences have you experienced due to drug or alcohol abuse? Educational Level - BPSA Highest Grade/Degree Completed: Can you read and write? yesNo Have you had vocational training? Are you a student? yesNo How do you learn best? By seeing thingsBy hearing thingsBy touching thingsBy writing thingsBy reading thingsOther Other: Do you have any diagnosed learning disabilities including attention deficit hyperactivity disorders? yesNo Explain: Does this affect you today? yesNo How? Vocational Screen - BPSA Are you currently employed? yesNo Explain: Do you need assistance developing job skills or find a job? yesNo Have you ever missed work or lost a job due to your substance use? yesNo Explain: What is your current financial status? Self SufficientSupported by FamilyStruggling How does your financial status affect your addiction? Do you have other resources and/or benefits? (SNAP, pension, rental assistance?) YesNo Explain:
