Diamond Tree Questionnaire
For more info about Diamond Tree Recovery please visit diamondtreerecovery.com
Email address *
For assistance Call-385-888-9624
Patient Name *
Your answer
Patient Date of Birth *
MM
/
DD
/
YYYY
Reason you are seeking treatment *
Your answer
When would be the best time for you to enter treatment? Are you seeking Inpatient or outpatient treatment? *
Required
Please list current Drugs & or alcohol use, including amount & frequency? *
Your answer
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? *
Your answer
Are you currently employed? Where? Position?
Your answer
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? *
Your answer
Explain what is motivating you to get treatment and get well? *
Your answer
What financial resources do you have available to invest into your health & wellness? If you want to be considered for a Diamond Tree partial Scholarship please explain financial hardships *
Your answer
If you have insurance please provide; Insurance Company, Policy holder name, phone #, address & member ID #. *
Your answer
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of diamondtreerecovery.com. Report Abuse