Apply for Recovery Academy | Burning Tree West

House of Interest*

All housing assignments are based on clinical necessity. Your requests will be taken into consideration but our recommendation may differ.

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 check the box next to each item that 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:

Treatment Center
Hospital
Internet Search
Healthcare Provider
Sponsor
Family or Friend

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?*

Which Best Describes you or your loved one’s situation?

Have less than 30 Days Sober
Have 30 days sober or completion of 21-Day minimum primary treatment
Have a treatment plan or professional recommendation to go to sober living
Looking for sober living

Do you or your loved one need additional support developing key skills?

Yes
No

Do you or your loved one need help with any of the following?

Need extra support to help you successfully master school or work
Want help applying principles of sobriety to life.
Need clinical therapy to treat mental health and substance use disorder at the same time

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):

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.

Phone

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

Application