Application

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

  • Enter your Date of Birth
    MM slash DD slash YYYY
  • Which gender do you most identify with?
  • What is your martial status?
  • Emergency Contact

  • Substance Use History

  • MM slash DD slash YYYY
  • 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:
  • Please Select if you are Discharging from Another 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?

  • 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?
  • Do you or your loved one need additional support developing key skills?
  • Do you or your loved one need help with any of the following?
  • Other Information

  • 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

  • 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.