Admission Questionnaire

* Required fields
Name *
E-mail Address *
Do you speak and understand English? *
2. Vital statistics: Date of birth/ height/weight/occupation/marital status/children/address/phone *
3. Any medical problems? Which ones? Any allergies?(food,pets,meds) *
4. Any medications? Which ones? How long have you been taking these medications? Why do you take these meds?
5. Any mobility problems or physical limitations? Describe. *
6. Any psychiatric problems? Describe, including hospitalizations. *
7. Any suicidal attempts? Describe.
8. What treatment (rehab/detox) have you had in the past?Also, what is your substance abuse problem? (i.e. which drugs, alcohol??) Describe in detail. *
9. If you have had treatment in the past, what problems have you encountered in maintaining sobriety or staying drug free?(If no previous treatment, type "N/A")
10. If accepted into the program, do you have the necessary financial resources? *
11. How long a program will you be able to commit to? {Programs run from 4 to 12 weeks} *
12. Do you have a valid passport? *
13. What are your hobbies/recreational activities/spare time activities?
14. Do you have any special dietary needs/allergies/preferences? Describe.
15. What is the requested date of admission? *
16. What is the airport city you would be flying from? What other airports are nearby? *
17. Are there any special needs or requests?
18. How did you hear about us? *
19. Any questions? Please ask.

I have read and agree to the Privacy Policy *

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We currently have a waiting list for some dates. Please submit your questionnaire and we will get back to you. There is no obligation . No reservations will be made until we have spoken to you and approved you for admission. No fees are due at this time.

If accepted for admission, a deposit will be requested to guarantee your spot. Remember we are not a 'factory' recovery center. There are no more than 8 clients at any one particular time.

CALL: 888-OCEAN 80 (888-623-2680) or 954-993-7246 Kathy/Intake Coordinator