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
Occupation:
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?
Please describe which areas are affected
If yes: explain why these programs were not safe or sufficient for you
Preferred program type: Residential / IOP / Other Residential IOP PHP Other
Mental Health & Risk History Previous mental health diagnoses
If yes: include dates and last occurrence if known
If yes: include dates and last occurrence if known
If yes: include dates and last occurrence if known
If yes: provide details
COLUMBIA SUICIDE SCREENING Have you been thinking about how you might do this?
Have you had these thoughts and had some intention of acting on them?
Examples: Collected pills, obtained a gun, gave away valuables, wrote a will or suicide note, took out pills but didn’t swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn’t jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.
Substance Use If yes: indicate frequency and last use of each substance
If yes: provide details
If yes: provide details
Trauma & Unsafe Environment Other (please explain to the extent you are comfortable)
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
If yes: specify type of reaction (e.g., rash, anaphylaxis, gastrointestinal upset, other)
Please list any hospitalizations, surgeries, or serious medical conditions
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 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
SELF CERTIFICATION FORM Submit
