First Name:

Client first name

Last Name:

Client last name

Gender assigned at birth:

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Do you identify as transgender or non-binary?

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Phone Number:

Client phone

Email:

Client email

If you dont have a phone or email, how will we reach you:

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What is your drug(s) of choice?

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When was the date of your last use?

Date

Are you at risk of having withdrawals?

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Do you have a history of seizures or DTs?

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Birthdate: (Enter year before month and date)

Client birthdate

Do you have Active Medicaid?

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Do you have any of the following: 

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What is your Medicaid Member ID or Social Security Number? This way can verify your benefits:

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Do you have any chronic health conditions?

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If yes to the previous question, please describe below.

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Have you been diagnosed with any mental health conditions?

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If yes to the previous question, please describe below.

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Are you able to ambulate (walk around) without assistance?

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Please list any medications you are currently prescribed below.

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Are you or could you possibly be pregnant?

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Do you understand that you are required to have medicaid to apply for our Embark Program (60 days no cost, 6pm curfew, groups 7 days per week;) And the Ascent Program ($900/month, 3 groups a week, 10pm curfew non-group days) Which program are you are applying for?

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Have you been in treatment in the last 6 months?

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If yes, please state where and when you were in treatment.

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Have you been in sober living before?

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If yes, please state where you were and the dates you were there.

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Employment Status:

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If you are employed please list your employer and how much you make per month:

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Referred by:

Client Referred By

If not listed, where did you hear about us:

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Are you currently on Probation or Parole? Please also include the County. If there are more than one please list all:

Text field

Are you required to register as a sex offender in the state of Colorado?

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Hace you ever been convicted of arson?

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Do you work with any of the following (select all that apply):

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Are you currently required to take monitored UAs anywhere?

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An Emergency Contact is required, who will you want to put for an Emerency Contact? Include first and last name, phone number and their relationship to you:

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Are you currently, or will you be on SSDI in the next 60 days?

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Do you think you can meet the working requirement of 40 hours per week?

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Do you agree to find employment immediately upon joining the program? 

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If you are case management or law enforcement making this referral, please give your name, who you are with, your phone number, and your email address below:

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Do you understand that our program is designed for people who are willing to work and as such you will be expected to find employment and begin working in two weeks from your admit date?

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Mountain West is not responsible for resident transportation or bus passes for its residents. Do you understand that you will be responsible for your own transportation while a resident at Mountain West?

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By checking this box, I am stating that all information provided has been truthful, and if it is found that I was not truthful with the information provided on this form it could be grounds or immediate discharge from the program:

Checkboxes

By checking this box, I consent to receive text messages from Mountain West Recovery at the phone number I provided.

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