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Home
Locations
Recovery for Men
Recovery for Women
Women and Women with Children
FAQ
Book 180 at Your Church
About Us
News
Student Testimonies
Winter Newsletter
Wishlist
Media
Shop 180 Merchandise
Media Kit
Contact
Donate
Apply to
180
MINISTRIES for Women and Women with Children, Olathe Colorado
About You
Name
*
First Name
Last Name
Phone Number
*
(###)
###
####
Email
*
Do you have health insurance or Medicaid?
*
Medicaid
Health Insurance
Neither
Health Insurance Provider:
Mental Wellness
Are you currently taking any medications?
*
No
Yes, if yes, what medication, and for what condition?
Medication and Condition:
*
Have you ever been diagnosed with any mental illness or had any mental health issues in the past?
*
No
Yes, if yes, please explain:
Mental Health Diagnosis or Issues:
*
Are you currently being treated for mental health illness?
*
No
Yes, please explain:
More details:
Legal Issues
Are you on parole or probation?
*
No
Yes, if yes:
Probation officer name and phone number:
Do you have any upcoming court appearances?
*
No
Yes
If so, what are the charges and what are the dates?
What is your public defender or attorney's name and contact information?
Tuition and Payment Arrangements
Do you have the means to pay the tuition for your time at 180 Ministries? If not, please list anyone that may be able to help you with the cost of your residential recovery services.
*
Yes
No
Name, relation and contact number of possible patrons that might assist you in paying for your care.
Substance Misuse Disorder History
Drug of Choice
*
Opiates (Heroin, Oxy, Fentanyl)
Stimulants (Cocaine, Adderall, Meth)
Alcohol
Hallucinogens
Anything and Everything
Are you currently USING or ADDICTED to any substance, if so, how much and how often do you dose? Are you experiencing withdrawls symptoms, or do you expect to when you stop using?
How many treatment centers have you been to before today?
*
This will be my first time
Once
Twice
Three or more
Did you complete the treatment program or leave prematurely? If left, reason for leaving:
Referral
Name of person who referred you to 180 Ministries?
*
What do you hope to get out of this program, and are you willing to do whatever it takes while you are in the program to help yourself to make positive changes?
*
What is your reason for seeking treatment today?
*
Can you give a brief description of the circumstances surrounding your decision to seek treatment?
*
Please provide contact information for at least three contacts
*
Examples would be parents, pastor, sponsor, spouse, friends:
First Name
Last Name
Phone
(###)
###
####
Name
First Name
Last Name
Phone
(###)
###
####
Name
First Name
Last Name
Phone
(###)
###
####
Thank you!