Crestone Residential Treatment Services Application

General Applicant Information

Name *

First Name Last Name

Maiden Name or Aliases

First Name Last Name

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number *

Date of Birth *

Date

Social Security Number *

Gender *

Male Female Custom

Referral Source

How did you hear about us?

Annual Family Income *

SSDI (Social Security Disability Insurance)

If applicable

SSI (Suplimental Security Income)

If applicable

Other income

If applicable

Insurance (Please check all that apply) *

None Medicare Medicaid Self-Pay Private Insurance

Private Insurance Information (If Applicable)


Name of Private Insurance Company
Insurance ID Number
Group ID Number
Insurance Phone Number
Name of Policy Holder

Substance Use and Mental Health Treatment History

Please list a history of drug/alcohol treatment including residential, hospital, or outpatient. DO NOT include detox or DUI.

List of Treatment History *

Have you participated in a Health Solutions treatment program before? *

Yes No

When?

What type of treatment?

Have you ever been told you have a mental health condition? *

Yes No

Please list condition(s)

Please list all substances used including alcohol, tobacco, marijuana, illegal drugs and prescription drugs. Please list in the order of use starting with the most recent.

Substance Use History *

Legal History

List of Legal History *

Are you currently incarcerated? *

Yes No

Are you currently involved in the following (check all that apply) *

Probation Parole Hold Orders Duty to Warn Restraining Order Pending charges Will serve jail/prison time after treatment None of the above

Please explain:

Probation/Parole Officer (If Applicable)

Name

Probation/Parole Officer Phone Number

Are you a registered sex offender? *

Yes No

Medical Information

Do you have a Primary Care Physician? *

Yes No

Who is your Primary Care Physician?

Please list past or current medical conditions/surgeries/specialty concerns *

Are you currently pregnant? *

Yes No

If yes, when is the expected due date?

Do you require any special accomodations for physical activities? *

Yes No

If Yes, please explain:

Do you have any allergies? *

Yes No

If Yes, please explain:

List all CURRENT medications (mental health & physical) *

Written Response Section

For each of the following questions, please give complete answers in paragraph form. Answers should range between 3-5 sentences each.

What is your motivation for receiving treatment at this time? *

What do you hope to gain from completing treatment at this time? *

Name at least THREE difficulties you will have to address to maintain your recovery. Please elaborate and further explain each difficulty listed. *

Imagine you have sustained your recovery for 15 years. As you look back on your life, what will have taken place, what will have been your action steps to get here, and who do you see around you who will have helped support you to achieve your recovery? *

Reminder to all applicants, please note:

If you have a copy of a psychiatric evaluation completed in the last year, further documentation will need to be provided.
If you are a registered sex offender, you will need to provide documentation of treatment.
It is important to your care and treatment that you fill out the application completely.
Feel free to add additional paperwork you consider helpful or necessary.

Please acknowledge the following Terms & Conditions:

I Understand the Crestone Residential Treatment Services program is a tobacco and vape product free environment, no smoking will be allowed during the duration of the program. Nicotine replacement medications may be available for all participants.
I agree that if I am a registered sex offender, I will need to provide documentation of treatment completion.
In order to be considered for admission the application must be completed fully, incomplete applications may delay my consideration for the program.
I understand that it is my responsibility to contact the admission coordinator if my contact information changes, if I fail to do so I might miss contact attempts to coordinate my admission to The Crestone Residential Treatment Services program.
I understand that part of Crestone Residential Treatment Services programming involves mild physical activity on a daily basis and am willing to participate to the best of my ability.
I understand that in order to be admitted to the program a full physical with lab work will be completed with Health Solutions Medical Center prior to admission on the day of my admission to medically clear me for participation in The Creston Residential Treatment Services program.
I commit to working with the admission team to be fully detoxed from all substances prior to my admission to the Crestone Residential Treatment Services program. The admission coordination team is happy to help coordinate admission to a detox program prior to my admission to the program.
I have reviewed The Crestone Residential Treatment Services Program Handbook, and commit to follow all the expectations for behavior and understand that failure to do so may eventually result in my discharge from the program.