• Crestone Residential Treatment Services Application

  • General Applicant Information

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  • 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. 

  • 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.

  • Legal History

     
  • Medical Information

     
  • Written Response Section 

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

  • 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.
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