Personal & Demographic Information

First Name

Last Name

Date of Birth

Age

Gender Identity

Pronouns

Sexual Orientation

Phone Number

Email Address

Permanent Address

Emergency Contact Name

Emergency Contact Relationship to Client

Emergency Contact Phone Number

Do you have any children? (Yes/No)

Yes No

Occupation:

Are you currently working with an educational or therapeutic consultant?

Yes No

Please provide their name and contact info

How did you hear about Corner Canyon?

Religious or spiritual affiliation (optional)

Current Concerns & Functional Impairment

What are the main issues that led you to seek treatment now?

Do your current symptoms prevent you from safely taking care of yourself (e.g., eating, hygiene, medications, attending appointments)?

Yes No

Please describe which areas are affected

Have you previously tried outpatient, PHP, or IOP programs for these issues?

Yes No

If yes: explain why these programs were not safe or sufficient for you

Preferred program type: Residential / IOP / PHP / Other

Mental Health & Risk History

Previous mental health diagnoses

Have you engaged in self-harm or attempted suicide in the past 30 days or previously?

Yes No

If yes: include dates and last occurrence if known

Have you engaged in aggressive behavior toward others in the past 30 days or previously?

Yes No

If yes: include dates and last occurrence if known

Have you ever experienced mania, psychosis, or hallucinations in the past 30 days or previously?

Yes No

If yes: include dates and last occurrence if known

Any current thoughts of self-harm, suicide, or harming others?

Yes No

If yes: provide details

COLUMBIA SUICIDE SCREENING

Have you wished you were dead or wished you could go to sleep and not wake up?

Yes No

Have you actually had any thoughts of killing yourself?

Yes No

Have you been thinking about how you might do this?

Have you had these thoughts and had some intention of acting on them?

Have you started to work out or worked out the details of how to kill yourself? Do you intend to carry out this plan?

Yes No

Have you ever done anything, started to do anything, or prepared to do anything to end your life?

Yes No

If yes: ask: Was this within the past three months?

Substance Use

Have you used alcohol, cannabis, or other substances in the past 12 months?

Yes No

If yes: indicate frequency and last use of each substance

History of withdrawal, overdose, or treatment for substance use

Yes No

If yes: provide details

Do you engage in other compulsive or addictive behaviors? (e.g., gambling, sexual behaviors, pornography, spending)

Yes No

If yes: provide details

Trauma & Unsafe Environment

Have you experienced trauma, abuse, or violence?

Yes No

Does your living situation make it unsafe or difficult to manage your mental health outside of 24-hour care?

Yes No

If yes: provide details.

Medical History

Please list all current medications, including dosage, frequency, and reason/condition being treated

Please list any supplements or vitamins you regularly take

Do you have any allergies?

Yes No

If yes: specify type of reaction (e.g., rash, anaphylaxis, gastrointestinal upset, other)

Please list any hospitalizations, surgeries, or serious medical conditions

Do you experience chronic pain or other ongoing medical issues?

Yes No

If yes: specify

Do you have any limitations in daily functioning (bathing, dressing, preparing meals, managing finances, attending appointments)?

Do you have any upcoming scheduled appointments with an outside provider that would take place while in our care?

Legal History

Any current or past legal issues or probation?

Yes No

If yes, please explain

Optional legal history specifics: prior restraining orders, domestic violence charges, DUI or other court interventions

Individualized Needs

Please list any needs you may have that have not been addressed in this application

Consent & Certification

I certify that the information provided in this application is accurate and complete

Yes No

I consent to allow Corner Canyon to request records from my current or previous clinicians as needed

Yes No

I acknowledge that my information will be stored and used according to HIPAA regulations and Corner Canyon’s privacy policies

Yes No

I acknowledge that my information will be stored and used according to HIPAA regulations and Corner Canyon’s privacy policies

Yes No

SELF CERTIFICATION FORM

I hereby certify that, to the best of my knowledge, the provided information on this application is true and accurate. I acknowledge that any misrepresentation, omission, or change of information on this application may result in, but is not limited to, changes to the status of my admission including a potential discharge, changes to level of care, or other changes seen best fit by Corner Canyon Health Centers and their representatives. I also acknowledge that Corner Canyon Health Centers and their representatives may not change any responses on this application at any time but may add notes at their discretion to add any additional pertinent information or context surrounding this application.

Apply for Mental Health Treatment

Personal & Demographic Information

Current Concerns & Functional Impairment

Mental Health & Risk History

COLUMBIA SUICIDE SCREENING

Substance Use

Trauma & Unsafe Environment

Medical History

Legal History

Individualized Needs

Consent & Certification

SELF CERTIFICATION FORM