Application for Admission Are you completing this form for yourself or a family member? Myself Family Member Select Class or Service * Coaching Counseling Medication-Assisted Treatment (MAT) Anger Management - Mad for What? Anger Management - Alternative to Violence Lift the Streets - Phase 1 Lift the Streets - Phase 2 Lift the Streets - Phase 3 Self Esteem Class Breaking Codependency 7 Habits for Highly Successful People 7 Habits for Highly Effective Teens Relapse Prevention Trauma Healing Victim Empathy Underage Tobacco and Vaping Intensive Drug and Alcohol - 2 Day - 18 and up Intensive Drug and Alcohol - 2 Day - 17 and under Marijuana THC Class Parenting Young Offenders - 1/2 day - 10-12yr Young Offenders - 1/2 day - 13-17yr Petty Theft Name (Patient) * First Name Last Name Date of Birth MM DD YYYY Gender Female Male Prefer not to answer Email * Phone (###) ### #### Primary Care Physician Current Therapist / Counselor Therapist / Counselor's Phone Number Please list the problem(s) which you are seeking help for? * Depressed Mood Excessive Worry Impulsivity Alcohol Addiction Drug Addiction Violence Anger Avoidance Concentration/Forgetfulness Suspiciousness Racing Thoughts Anxiety Attacks Increase in Risky Behavior Excessive Guilt Thoughts of Harming Yourself/Others Have you ever had feelings of thoughts that you didn't want to live? Yes No Do you current feel that you don't want to live? Yes No How often do you have these thoughts? How did you hear about us? Option 1 Option 2 Message * Thank you!
