ALPINE RETREATS Application for Admission
Please print this form, complete and email or FAX to
(970) 944-2477This application will be reviewed by an admissions counselor and you will be contacted within 24-hours.
Name of person filling out this form (First, Middle, Last)
: ______________________________Relationship to patient:_____
PATIENT INFORMATION
Patient Name (First, Middle, Last):_______________________________
Address: ________________________ State: __ Zip:_________ Phone 1:______________
Phone 2: _____________________ E-mail address: ___________________________Social Security Number:
__________________________ DOB: ____________________Gender: Male ( ) Female ( )
Occupation: _____________________ Marital Status: __________________Children? Names, Gender and Ages? ____________________________________________
What is your primary addiction? Include alcohol, prescription drugs and/or street drugs.
Name of Drug(s): ___________________________________________
How long have you used each?_____________________________________
Quantity of each: __________________________________________________
Have you ever been to treatment before? (If so, please include outpatient programs)
IF SO: When? What facility? How long? Did you complete
treatment? _______________________________________________________________
Was the treatment 12 - Step based? Yes ( ) No ( )
Have you ever attempted to stop drinking or using?
Yes ( ) No ( )If yes, did you experience any of the following? Please circle those options that apply to you.
Seizures: Shakes: Tremors: Swelling: Headaches: Nausea: Vomiting:
Are you now or have you ever seen a Psychologist, Psychiatrist, Therapist or Counselor? Yes ( ) No ( )
If so Why? _________________________ Were you given a diagnosis? Yes ( ) No ( )
If so what was the diagnosis? _________________________
Were you placed on any medication? Yes ( ) No ( )
If so what medications and dosages? ________________________________________________
Have you thought, planned or attempted suicide? Yes ( ) No ( )
If so, When? ______________ Were you under the influence at the time? Yes ( ) No ( )
Have you been ill or hospitalized in the past 30 days? Yes ( ) No ( )
If yes, please explain: ____________________________________________________________
Do you have any medical problems or physical pain? Yes ( ) No ( )
If yes, please describe: ___________________________________________________________
Are you taking any prescribed medications? Yes ( ) No ( )
If yes, please tell us what medications, what dosage, what frequency and who is prescribing them:
_____________________________________________________________________________
Are you able to walk, feed, dress, bathe and care for yourself? Yes ( ) No ( )
Do you have any legal problems from your use? Yes ( ) No ( )
Have you driven under the influence? Yes ( ) No ( )
Have you lost a job due to your use? Yes ( ) No ( )
Have you missed work/called in sick due to your use? Yes ( ) No ( )
Do you have trouble sleeping at night? Yes ( ) No ( )
Has your appetite changed? Yes ( ) No ( )
Are you liver enzymes elevated? Yes ( ) No ( )
Has your Doctor ever told you to stop drinking? Yes ( ) No ( )
Are you isolating from your family and friends? Yes ( ) No ( )
Is there a history of addiction in your family? Yes ( ) No ( )
Are you able to pay your bills? Yes ( ) No ( )
Who can we call on your behalf in case of an emergency? (Name, Address, Phone)
_____________________________________________________________________How will you be paying for your treatment? Please check one of the options below:
Cash ( ) Cashiers Check ( ) Money Order ( ) Credit Card ( )
Print and email or fax.