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PERSONAL INFORMATION
First Name and Last Name:               Email:  
Name you like to be called:    
       
MAILING ADDRESS PHYSICAL ADDRESS (Same as Mailing Address)
Address: Address:
City/State/Zip: City/State/Zip:
 
 
Home Phone: (XXX-XXX-XXXX) Work Phone: (XXX-XXX-XXXX)
Sex: Male        Female SSN:
Date of Birth: / /
Were you adopted and raised by adoptive parents? Yes        No    
Marital Status: Employment Status:
Employer or Business Name: Position/Title:
Employment Address: City/State/Zip:
Name of spouse or significant other: Phone (if different):
Who to contact in emergency: Phone (if different):
Name of Physician:    
Address: City/State/Zip:
Phone:    
Date of Last Physical Exam: Results:
Are you currently under medical care? Yes        No
Current Medications:       None
Are there any immediate health concerns? Yes        No
If "Yes," please describe:  
Are there any physical disabilities? Yes        No
If "Yes," please describe: Any history of head injury? Yes        No
Describe any long-term illnesses:       None

Have you ever had life-threatening symptoms during withdrawal?

 Yes        No
History of DT's or seizures? None    Mild    Moderate    Severe
Dietary restrictions and preferences:       None
List any allergies:
Any current legal problems? (e.g. divorce, custody issues, DUI, etc)       None
Have you ever been charged for or convicted of a crime?       None
Are you required to enter treatment due to:
Criminal Justice System   Social Services   Work
Family member   Other   None

HISTORY OF CHEMICAL DEPENDENCY
SUBSTANCE USED

If Alcohol, What Kind?
If Drug, Intake Method?

 Date of
First Use		 Date of
Last Use		 Frequency of Most
Recent Usage		 Amount
Describe any and all problems or conditions that you see as related to the addiction (e.g. medical, emotional, relationships):
Describe other problems in your life that you see as unrelated to the addiction:
Other excessive behaviors:
Workaholic   Gambling   Spending
High sugar intake   Exercise to extreme   Compulsive sexuality
Bingeing/purging   Excessive fasting   None
Do you smoke cigarettes?
Yes   No   If yes, how much? 
Do you chew tobacco?
Yes   No
List all family and generational
history of substance abuse:		       None
Why are you seeking treatment at this time?

PREVIOUS COUNSELING / TREATMENT EXPERIENCE
List previous inpatient and/or outpatient facilities you have attended and therapists you have worked with:
NAME OF FACILITY /
THERAPIST 		Location Dates Phone # Treated For Inpatient /
Outpatient
I have not attended any inpatient and/or outpatient facilities before.

PSYCHIATRIC HISTORY  
Enter current or previous psychiatrist you’ve worked with:
Name of psychiatrist: Phone #:
Diagnosis: Dates treated:
Prescribed medications:

SIGNATURE
For your benefit, it is important that the above information be truthful and that you not omit anything. By clicking "I Agree" below, you are agreeing that you understand that your treatment at Desert Canyon Treatment Center will be based on the information that you are providing here and that this information is true and complete.

YOUR APPLICATION WILL NOT BE PROCESSED WITHOUT YOUR AGREEMENT TO THIS STATEMENT

    I AGREE 
DEPOSIT AGREEMENT
The cost for treatment at Desert Canyon is $19,000 for 28 days. To reserve a bed and ensure admission for a preferred arrival date, a $2,000 deposit is required. This deposit is non-refundable. This deposit can be applied to treatment within one year of it being received, however, if you change your arrival date, we cannot guarantee availability. Payment (minus deposit) is due upon admission. By clicking "I Agree" below, you are acknowledging that you have read, understand and agree to this policy regarding the nonrefundable deposit.

YOUR APPLICATION WILL NOT BE PROCESSED WITHOUT YOUR AGREEMENT TO THIS POLICY

    I AGREE 
PAYING WITH INSURANCE
DO YOU PLAN TO PAY WITH INSURANCE?  
Yes   No
(If you select "No" you may be automatically taken to the next section.)
 

To pay for treatment with insurance, Desert Canyon requires payment of your deductible, your coinsurance and 50% of the insurance copay at the time of your admission. As soon as Desert Canyon receives payment from your insurance company, the payor will be refunded any and all overpayment.

PRIMARY INSURANCE
Insurance Company:
Address: City/State/Zip:
Customer Service Phone:
ID/Policy #: Relation to Applicant:
Group #: Group Name:
Name of Policyholder: (Same as Applicant)
Policyholder Address: Policyholder City/State/Zip:
Policy Holder SSN: Date of Birth:

If insurance is through the policyholder's employer, please complete:
Name of Employer:
Address: City/State/Zip:
Employment Status :
SECONDARY INSURANCE (if any)
Insurance Company :
Address: City/State/Zip:
Customer Service Phone:
ID/Policy #: Relation to Applicant:
Group #: Group Name:
Name of Policyholder: (Same as Applicant)
Policyholder Address: Policyholder City/State/Zip:
Policy Holder SSN: Date of Birth:

If insurance is through the policyholder's employer, please complete:
Name of Employer:
Address: City/State/Zip:
Employment Status :

INSURANCE AUTHORIZATIONS

AUTHORIZATION TO RELEASE INFORMATION: I hereby authorize Desert Canyon Treatment Center to release any information required for payment or to process claims in the course of my treatment which may include HIV, Communicable disease or drug abuse information. This assignment will refer to copies and fax tranmittals and will remain in effect until revoked by me in writing.

AUTHORIZATION TO PAY: I hereby authorize payment directly to Desert Canyon Treatment Center for benefits otherwise payable to me for services. I understand that I am ultimately responsible for all services rendered to me regardless of insurance or other legal issues. This assignment will remain in effect until revoked by me in writing.

INSURANCE AGREEMENT: Insurance companies do not guarantee payment even after benefits have been quoted. In addition, they usually don’t disclose their allowables until after a claim has been submitted, which is after you have completed your program. Finally, insurance companies usually quote benefits as a percentage of what they consider a reasonable and customary expense, an amount that differs considerably from one company to the next. While we consider the cost of our program to be very reasonable and competitive, we cannot guarantee total coverage by your insurance company. Desert Canyon makes full effort to collect insurance payment. However, in all situations, you are responsible for full and total payment of the fees of the program.

By clicking I AGREE below, you are authorizing Desert Canyon as described above and you are agreeing to the Insurance Agreement. If you are using insurance for payment, your application will not be processed without this agreement.

    I AGREE 

MEDICAL/PSYCHIATRIC RELEASE
IF YOU ARE CURRENTLY UNDER MEDICAL OR PSYCHIATRIC CARE, PLEASE COMPLETE THIS SECTION.
IF YOU ARE NOT UNDER MEDICAL OR PSYCHIATRIC CARE, YOU CAN SKIP THIS SECTION.
If you are currently under medical or psychiatric care, Desert Canyon may need to obtain information from your physician before you can be admitted.
Please complete the information below so we can do so in order to assist your admission to Desert Canyon.
To: (Name of Physician)   Of: (Facility name)
Address: City/State/Zip:
Phone:
By clicking "I Agree" below, I hereby authorize Desert Canyon staff to contact you for the release of information pertaining
to your medical and/or psychiatric condition.

Authorization expires one year from date of signature.
    I AGREE 

MISCELLANEOUS
How did you first find out about Desert Canyon?  
If Magazine, Web Site or Search Engine, please name:

When you have finished filling in the above information, please click on the "Submit Form" button below to send us your Application. By submitting this form, you are acknowledging that you have read the information presented here, all information entered is true and correct and your are agreeing to the above policies.

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