Prescreening Form
Fill out all questions and you will be added to the wait list. We have two residential facilities and we will place you at the facility that we feel will be the best fit for your healing journey. 

If you have any questions filling this out or about treatment options please reach out to 
Tyler Rogers 801-917-7431
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Full Legal Name
Date of Birth
Phone number
Email
Place of Living
Insurance Type (Name of Insurance)
Policy Number
Social Security Number
Gender Identification 
Pregnant
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Substance Use: Any and All Substances
Substances:
Amount Used:
Frequency of Use:
Route:
How long have you been using?
Date of Late Use:
Do you need Detox services?
Have you attempted suicide in the last 30 days?
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Have you had self harm in the last 30 days?
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Do you have any physical health concerns? Including medical conditions; asthma? heart? high blood pressure? Traumatic brain injuries? Seizures?
Do you have any physical limitations that limit daily activities like walking up stairs, walking around the block, performing chores, or any other physical activity? if so, what is the limitation(s)?
History of Seizures? If yes, please list the last date of your most recent seizure. Also include if you are on any medications for seizures. 
Any Allergies to food, medication, or environment?
Have you been diagnosed with a mental health disorder? If so, what are they?
When sober, do you see or hear things that are not really there?
If yes, please explain.
Have you had any legal charges for acts of violence or of a sexual nature? If so, please explain. 
What medication(s) are you currently taking? 
Our program does not allow for some medications; Benzodiazepines (Xanax, Valium), Testosterone, Lyrica, stimulant medications (Adderall), opiates (Lortab, Percocet), etc. You will not be able to take these medications while in treatment. We do allow individuals to be on buprenorphine injections (sublocade or brixadi). Can accommodate a sublingual buprenorphine (suboxone) taper if medications are prescribed before admission to program. Do you agree to our medication policy?
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What is your motivation for treatment?
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