Application

First Name*

Last Name*

Date of birth*

Phone*

Email*

Consent to contact*

Yes

No

Sex*

Do you have any physical limitations?*

Can you walk, run, hike, swim?*

Yes

No

Can you lift 50lbs or more?*

Yes

No

Personal/Emergency Contacts

First Name*

Last Name*

Phone*

Relationship*

First Name*

Last Name*

Phone*

Relationship*

Drugs of choice*

Last time used and when*

How many years*

Allergies*

Any health/physical conditions*

Do you have seizures?

If yes, how often and what medications are you taking? If no, just put no.

Do you require any medical equipment?*

Yes

No

Do you have a history of self harm or thoughts of self harm?*

If yes, please list above, if no, just put no.

Do you have a history of suicide attempts or suicidal ideations?*

Yes

No

Mental health services*

Yes

No

Are you taking any prescribed medications?*

If yes, please list above, if no, just put no.

Are you participating in a drug replacement program (MAT)*

Yes

No

Are you currently in treatment?*

Yes

No

Have you been through any other treatment programs?*

Yes

No

Do you have any legal obligations or requirements?*

If yes, please list above, if no, just put no.

Have you been charged or convicted of arson?*

Yes

No

Have you been charged with any violent crimes?*

Yes

No

Have you been charged or convicted of a felony?*

Yes

No

Have you been charged with neglect?*

Yes

No

Are you on probation or parole?*

If yes, please list officer name and number, if no, just put no.

Sex offender?*

Yes

No

How did you hear about us?*

Do you have any Orders of Protection in place or against you?*

Yes

No

Do you have any personal relationships with staff*

Yes

No

Have you previously applied to Beacon Treatment Center?*

If yes, when? If no, just put no.

Referral source*

Court

Detox facility

Tribal organization

Non-profit

Treatment center

Mental health facility

Halfway house

Emergency room

Counselor

Event

Other

Application

Personal/Emergency Contacts

Contact

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