Application

  • Do you want a single room to yourself or do you want to share a room?
  • General Information

  • Which gender do you most identify with?
  • What is your marital status?
  • Emergency Contact

  • Legal Information

  • Substance Use History

  • Substances you used/abused (check all that apply)
  • Are you discharging from a substance abuse facility?
  • Treatment History: please list the treatment centers you have been to and the year you admitted. (Including detox, RTC, IOP, and sober livings)
  • How did you Hear About Us?

  • Referral Type:
  • Medical Information

  • Other than addiction, are you being treated for any other physical or mental conditions?
  • If yes, please describe:
  • If you are taking prescribed medications, please list the name, dosage, and purpose of each, below.
  • Other Information

  • Will you be bringing a vehicle?
  • If so, please provide year, make, model and color:
  • Will you be using Private Insurance to pay for IOP services?
  • Provide insurer and type (PPO/MHO):
  • I, the undersigned, submit that the information contained herein is true to the best of my knowledge and accept that false information or omissions of information may cause services with Burning Tree West to be terminated. Please type your name.
  • This field is for validation purposes and should be left unchanged.