Name *

First Name

Last Name

Phone Number *

(###)

###

####

Do you have health insurance or Medicaid? *

Medicaid

Health Insurance

Neither

Are you currently taking any medications? *

No

Yes, if yes, what medication, and for what 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:

Are you currently being treated for mental health illness? *

No

Yes, please explain:

Are you on parole or probation? *

No

Yes, if yes:

Do you have any upcoming court appearances? *

No

Yes

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

Drug of Choice *

Opiates (Heroin, Oxy, Fentanyl)

Stimulants (Cocaine, Adderall, Meth)

Alcohol

Hallucinogens

Anything and Everything

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

(###)

###

####