Diamond Tree Initial Application
For more info about Diamond Tree Recovery please visit diamondtreerecovery.com
Email *
For assistance Call-385-888-9624
Patient Name *
Patient Date of Birth *
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Phone Number *
Reason you are seeking treatment *
Are you seeking Inpatient or outpatient treatment? *
Required
Please list current Drugs & or alcohol use, including amount & frequency? *
Have you had any of these mental health concerns in the past 3 months? *
Required
Do you have any pending criminal charges or history of aggressive crimes? *
Are you currently employed? Where? Position?
Do you have a safe home environment to return to after treatment? *
Required
What other treatment programs or methods have you tried? What has worked for you? What has not worked for you? *
Explain what is motivating you to get treatment and get well? *
What financial resources do you have available to invest into your health & wellness? If you want to be considered for a Diamond Tree Scholarship please explain financial hardships *
If you have insurance please provide; Insurance Company, Policy holder name, phone #, address & member ID #. *
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