ALPINE RETREATS Application for Admission

Please print this form, complete and email or FAX to (970) 944-2477

This 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 ( ) Cashier’s Check ( ) Money Order ( ) Credit Card ( )

Print and email or fax.