Online Admissions Form
Potential Clients Name
Name of person completing this application:
Your relationship to Client:
Your Phone Number
Street Address Line 2
State / Province
Postal / Zip Code
Person completing application's Email
Does Applicant Have:
Power of Attorney
Other representative of any kind
Reason Applicant is seeking residential care. Include current living situation:
If Applicant has a history of: Self Harm, Violence Sexual Promiscuity Substance Abuse Criminal Behavior or other high risk behaviors
Does applicant have any allergies, medical issues, or other physical wellness concerns?
Date of last physical:
Current PCP and address:
Current psychiatrist and contact information:
Person(s) financially responsible for applicants care
Averte is a private pay facility
How long do you anticipate being in treatment?
How did you hear about Averte? Did Someone Refer you?
Should be Empty: