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Referral and Program Placement Application

Please take a moment to fill out the form.

General Information

Application for Program Placement

Personal Information

Gender at Birth
Do you have the following items?
Have you served in the military?
What is your sexual preference?
Have you ever engaged in homosexual activity?

Marital Status

Choose One:
Do you have a girlfriend/boyfriend/fiancee?
Do you have children or dependents?

History

Have you ever experimented with alcohol or drugs?
Do you consider yourself addicted?
Have you ever had an eating disorder?
Any history of cutting?

Legal Status

Have you ever been arrested?
Do you have pending legal charges?
Have you ever been on probation?
Are you on parole?
Have you ever been in prison?

Spiritual Status

Do you believe in Jesus?
Have you committed your life to God?
How often do you attend church?
Are you a member of a church/religion?
Have you had any recent changes in your religious life?
Have you been involved in worshiping anything other than Jesus?

Financial Status

Are you receiving income from any of the following?
Do you have any outstanding debts/fines?

The Presenting Problem

Have you been to any other long-term programs?

Health Status

Do you have health insurance?
What is your general health?
Do you have any communicable diseases?
Do you have any of the following?
Are you receiving medical care?
Are you taking any medications?
Do you have any physical problems due to drugs or alcohol?
Have you ever had psychiatric care?
Have you ever attempted suicide?
Was it drug or alcohol related?
What is the condition of your teeth?

Thanks for submitting!

Fireside Collective Addiction and Treatment Center

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Fireside Collective is a non-profit organization with a 501(c)3 tax exempt status. All rights reserved.

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