Online application

    Are you working with an Educational Consultant?*

    Do you have children?

    Is your job in jeopardy at this time (Yes/No)

    Will you need assistance with FMLA/Disability paperwork? (Yes/No)

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

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

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

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

    Do you have any allergies? (Yes/No)

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

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

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

    Corner Canyon Health Centers has two(2) flights of stairs in the home. Are you able to move up and down the stairs safely and easily? (Yes/No)

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

    Do you have any dental problems or concerns? (Yes/No)

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

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

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

    Have you struggled to maintain daily activities such as showering/bathing, getting dressed, grooming, oral care, eating, cooking, medication management, housework, laundry, driving, or managing finances? (Yes/No)

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

    Substance Use History

    Have you ever used: alcohol, marijuana, amphetamines, cocaine, crack, heroin, oxy/roxys, percocets, xanax, klonopin, or other drug outside the use prescribed by a doctor

    Do you use tobacco products of any kind?

    Previous Mental Health Treatment

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

    Previous Mental Health Facilities and Level of Care

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

    Previous Substance Abuse Treatment

    Have you been to a treatment facility for substance abuse in the past? (Yes/No)

    Do you currently have any experience with any recovery community? (Yes/No)

    Do you have a sponsor? (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)

    Have you experienced any traumatic events in your life? (Yes/No)

    If yes, have you experienced any of the following

    Do you have any previous diagnosis for mental health? This may include one or more of the following: depression, anxiety, bipolar, or schizophrenia. (Yes/No)

    Do you have a previous DID diagnosis or a history of DID? If yes, a phone call with our clinical director or assistant clinical director must be completed prior to making a decision on the application as part of our pre-screening process. (Yes/No)

    Have you ever taken medications for any substance abuse or mental health diagnosis?

    Does anyone in your family have a history of substance use or mental health diagnosis?

    Are you currently experiencing any of the following (check all the apply):

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

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

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

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

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

    Are you currently experiencing any detox symptoms? (i.e. shakes, anxiety, sweats, cravings, nausea, body aches, etc.) (Yes/No)

    Are there any coping skills you find beneficial when you are struggling? (Yes/No)

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

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


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

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

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

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

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

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

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

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

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

    Legal History

    Any legal history? (Yes/No)

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

    Any pending court dates? (Yes/No)

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

    Covid Screening

    Have you had close physical contact with someone who has traveled to China, Iran, South Korea, Italy, Japan, Macau, Taiwan, or Europe in the past 30 days? (Yes/No)

    Do you know or suspect to have been in close physical contact with someone who has COVID-19? (Yes/No)

    Do you have any symptoms of illness? This may include one or more of the following: persistent cough, chest pains, shortness of breath, fever, fatigue, nasal congestion, runny nose, sore throat, diarrhea, nausea, etc. (Yes/No)

    Have you been following social distancing guidelines and self-quarantine/self-isolation? (Yes/No)

    Have you received the COVID-19 vaccine? (Yes/No)

    Individualized Client Needs

    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.

    Liz Lund, MPA

    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.