ADMISSIONS APPLICATION Name
Date
How did you hear about Corner Canyon?
Are you working with an Educational or Therapeutic Consultant? If so, who?
DEMOGRAPHICS Age:
Date of Birth:
How do you identify your sexuality?
Phone:
Email:
Permanent Address:
Occupation:
Whom is your support system?
If yes, please list the organization you affiliate with:
CLINICAL INFORMATION What happened in your life to lead you to seek treatment now (precipitating events)?
Why is Corner Canyon the program you are most interested in attending for treatment? Please be sure to include specific aspects of the program that you are interested in.
Please describe your current living environment.
Please describe your relationships with your family members.
Please describe some of your personal interests and strengths.
If so, please list them:
MEDICAL HISTORY Height:
Weight:
If yes, please list them below and include the dosage, frequency you take, and how long you’ve been prescribed for each and the reason for taking the medication.
If yes, please describe in detail.
If yes, please list them below and include the dosage, frequency you take, and how long you’ve been prescribed for each and the reason for taking the vitamins and/or supplements.
If yes, please explain
If yes, please explain.
If yes, please provide information in detail and include dates.
If yes, please explain.
If yes, please explain below.
Have you struggled to maintain any daily activities such as showering/bathing, getting dressed, grooming, oral care, eating, cooking, medication management, housework, laundry, driving, or managing finances? (Yes/No) Yes No
If yes, please explain which daily activities you are struggling with
If yes, please rate your chronic pain on a scale of 1-10 with 10 being the highest level of pain.
SUBSTANCE USE HISTORY Please list ALL substances that you have used in the last 12 months. Be sure to include the name, first and last use, the frequency and route of use, the amount used, and the use pattern over the last 12 months.
If yes, what kind of tobacco products?
PREVIOUS TREATMENT If yes, what has occurred since you were discharged that has led you to seeking treatment again?
Please list any treatment facilities you’ve been to previously and include the dates, reason for treatment, and the duration you were in treatment
Do you have a history of any other addictions or maladaptive coping? This may include one or more of the following: gambling, cutting/burning, self-harm, internet, pornography, sex, binging/purging/restricting, gaming, or sports (Yes/No) If yes, please explain.
Have you experienced any traumatic events in your life? (Yes/No)
If yes, please indicate who and what substances or diagnosis.
MENTAL STATUS EXAM If you checked any, please explain:
If yes, please describe the quality of your depressive episodes including the frequency, duration, the direct impact on your daily life and the date of your most recent episode.
If yes, please describe the quality of your depressive episodes including the frequency, duration, the direct impact on your daily life and the date of your most recent episode.
If yes, please describe the quality of your depressive episodes including the frequency, duration, the direct impact on your daily life and the date of your most recent episode.
If yes, please explain.
If yes, please indicate known causes of paranoia (i.e. drugs, mental health diagnosis, etc.)
If yes, please explain
Please list any known triggers or situations that can be triggering for you:
If yes, please explain.
COLUMBIA SUICIDE SCREENING
LEGAL HISTORY If yes, please explain.
If yes, please explain.
INDIVIDUALIZED CLIENT NEEDS Please list any needs you may have that have not been addressed in this application.
SELF CERTIFICATION FORM Submit
