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Applicants Name *

First

Last

Applicants Email *

Applicants Phone *

Date of Birth *

Clean/Sober Date *

Insurance Information *

What type of help are you seeking with Evolve? (i.e., Recovery House, Outpatient Treatment, or Residential Treatment) *

Are you currently using alcohol or drugs? *

What are your drugs of choice? *

What was your last date of use? *

Are you currently in treatment? If so what is the name of the treatment center, your counselor's name and email address, and projected discharge date? *

Are you currently incarcerated? If so where are you located and what is the name and number of your case manager?

Are you on suboxone, methadone, or Vivitrol maintenance? If so who is your prescribing doctor and what is your current dose?

Do you have any allergies? If so what are you allergic to? *

Do you have any mental health diagnosis? If so what are they? What medications are you currently taking, how long have you been taking them, and are you stable on those medications? *

Are you looking for Psychiatric Medication Management services and/or a mental health therapist?

Do you have any medical or health conditions? If so what accommodations are needed and what ongoing treatment do you have planned?

Do you have a primary care physician? *

Please list any other medications…

How do you plan on paying? Self pay, funding, or are you seeking scholarship options? *

Can you provide your own food?

Where have you lived in the past 2 years? *

Do you currently have a physical ID or driver's license? (If yes, which county are you a resident of according to that ID)? *

Are you currently on Parole or Probation? If so please provide the county, agent's name, and number in which you are on probation or parole. *

Have you been accused of or convicted of any sex offense? If so, please explain *

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