Apply for Recovery Academy | Burning Tree West

House(s) of Intrest?*

Life Skills House, Advanced Skills House, Sober Skills House

General Information

Full Name*

Address*

Date of Birth*

Enter your Date of Birth

Phone*

Best Email*

Which gender do you mostly identify with?*

Which gender do you most identify with?

What is your martial status?*

What is your martial status?

Emergency Contact

Full Name*

Phone*

Email*

Relationship*

Substance Use History

Sobriety Date

Longest Time Sober

Substances Used/Abused

On Substance Use Disorders*

Substance use disorders are classified as mild, moderate, or severe, depending on how many of the diagnostic criteria you meet. The 11 DSM-5 criteria for a substance use disorder include the following. Please select the item that BEST applies with a "yes" answer:

Are you Discharging from a Substance Abuse Facility?

Please Select if you are Discharging from Another Substance abuse facility.

If yes, what treatment center are you discharging from?

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?

How did you hear about us?

Please explain how you heard 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.

Personal Information

Which Best Describes you or your loved one's situation?*

Need Additional Support Developing Additional Life Skills?

Additional Help

Please describe any areas (other than addiction) you believe you or your loved one need help with in their life.

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?

Type of Insurance

Please select the type of insurance.

Insurance Company

Please type Insurance Company Name

Legal Information

Are you currently on probation or have pending charges? (Please provide detailed information):

Have you ever been convicted of any felonies?

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.

Name

This field is for validation purposes and should be left unchanged.

Application