Online Application

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:

Do you have any children? (Yes/No)

Yes No

Occupation:

Whom is your support system?

Do you affiliate with any religious organization? (Yes/No)

Yes No

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.

Do you have a primary care physician, psychiatrist, and/or therapist? (Yes/No)

Yes No

If so, please list them:

MEDICAL HISTORY

Height:

Weight:

Are you currently taking any medications, vitamins, and/or supplements? (Yes/No)

Yes No

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 and/or supplement.

Do you find the medication beneficial? (Yes/No)

Yes No

Have you ever taken any medication that you have had a negative reaction to? (Yes/No)

Yes No

If yes, please describe in detail.

Do you have any allergies? (Yes/No)

Yes No

If yes, please explain

Do you have any symptoms or concerns to address with the medical staff? (Yes/No)

Yes No

Are there any health concerns you have that would keep you from participating in treatment and/or physical activities? (Yes/No)

Yes No

If yes, please explain.

Have you been hospitalized in the past year for any medical concerns? (Yes/No)

Yes No

If yes, please provide information in detail and include dates.

Any history of blackouts, seizures, or DT’s? (Yes/No)

Yes No

If yes, please explain.

Any active eating disorders (i.e. restricting, over-eating, purging) or any history of eating disorders? (Yes/No)

Yes No

If yes, please explain below.

Do you have any dietary restrictions? (Yes/No)

Yes No

Any weight loss or gain of 10 or more pounds in the last 3 months? (Yes/No)

Yes No

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

Are you currently experiencing chronic pain? (Yes/No)

Yes No

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.

Do you use tobacco products of any kind? (Yes/No)

Yes No

If yes, what kind of tobacco products?

PREVIOUS TREATMENT

Have you been to a treatment facility for mental health or substance use in the past? (Yes/No)

Yes No

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

Have you had any psychological testing completed within the past year? (Yes/No)

Yes No

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)

Does anyone in your family have a history of substance use or mental health diagnosis? (Yes/No)

Yes No

If yes, please indicate who and what substances or diagnosis.

MENTAL STATUS EXAM

If you checked any, please explain:

Do you feel you are experiencing any symptoms of depression? (Yes/No)

Yes No

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.

Do you feel you are experiencing any symptoms of anxiety? (Yes/No)

Yes No

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.

Do you ever have panic attacks? (Yes/No)

Yes No

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.

Do you have a history of hallucinations? Either auditory, visual or tactile? (Yes/No)

Yes No

If yes, please explain.

Do you have a history of paranoia? (Yes/No)

Yes No

If yes, please indicate known causes of paranoia (i.e. drugs, mental health diagnosis, etc.)

Please list any known triggers or situations that can be triggering for you:

Are there any aspects of your daily life that you find too stressful or challenging to handle? (Yes/No)

Yes No

If yes, please explain.

Do you currently have or have a history of suicidal thoughts? (Yes/No)

Yes No

COLUMBIA SUICIDE SCREENING

1) Have you ever wished you were dead or wished you could go to sleep and not wake up? (Yes/No)

Yes No

2) Have you had any actual thoughts of killing yourself? (Yes/No)

Yes No

3) Have you been thinking about how you might kill yourself? (Yes/No)

Yes No

4) Have you had these thoughts and had some intention of acting on them? (Yes/No)

Yes No

5A) Have you started to work out or have worked out the details of how to kill yourself? (Yes/No)

Yes No

5B) Do you intend to carry out this plan? (Yes/No)

Yes No

6A) Have you ever done anything, started to do anything, or prepared to do anything to end your life? (Yes/No)

Yes No

6B) If yes to question 6a, how long ago did you do any of these?

Yes No

7A) Do you have any history of homicidal thoughts or ideation? (Yes/No)

Yes No

7B) If yes, do you have a plan? (Yes/No)

Yes No

LEGAL HISTORY

Any legal history? (Yes/No)

Yes No

If yes, please explain.

Any current or pending legal charges? (Yes/No)

Yes No

Any history of domestic violence or aggressive behavior? (Yes/No)

Yes No

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

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

Residential Program

We are specifically formulated to offer personalized therapeutic interventions to adult individuals with mental health disorders.

Intensive Outpatient Program (IOP)

We provide a comprehensive Intensive Outpatient Program (IOP) that offers clients the opportunity to attend group therapy sessions three to five times a week.

Have Questions
About Treatment?

Ask us about:

We work with most major insurance policies

We get reimbursement for 85% of our clients *We don’t take Medicaid or Medicare

Our Recent Blogs

April 24, 2024

10 Signs You Are Healing From Trauma

Liz Lund, MPA

Admissions Counselor
liz@cornercanyonhc.com

Liz is originally from lush green Washington State. She is a life enthusiast and a huge fan of people. Liz has always loved learning why people are the way they are. She moved to UT in 2013 and completed her bachelors degree in Psychology in 2016. After college Liz worked at a residential treatment center and found that she was not only passionate about people, but also administration. Liz is recently finished her MPA in April 2022. Liz loves serving people and is excited and looking forward to learning about; and from our clients here at Corner Canyon.

When Liz is not busy working she love being outdoors, eating ice cream, taking naps, and spending time with her precious baby girl and sweet husband.

ADMISSIONS APPLICATION

DEMOGRAPHICS

CLINICAL INFORMATION

MEDICAL HISTORY

SUBSTANCE USE HISTORY

PREVIOUS TREATMENT

MENTAL STATUS EXAM

COLUMBIA SUICIDE SCREENING

LEGAL HISTORY

INDIVIDUALIZED CLIENT NEEDS

SELF CERTIFICATION FORM

Residential Program

Intensive Outpatient Program (IOP)

Have Questions About Treatment?

Ask us about:

We work with most major insurance policies

Our Recent Blogs

10 Signs You Are Healing From Trauma

Liz Lund, MPA

Admissions Counselor liz@cornercanyonhc.com

Have Questions
About Treatment?

Admissions Counselor
liz@cornercanyonhc.com