Online Pre-Screening Application

If you or a loved one needs treatment, our pre-screening questionnaire is the quickest way to start the process. This questionnaire asks a range of questions including detailed histories of mental health, substance use, and medical procedures. The questionnaire also asks for your insurance information and any legal issues current or past. 

We collect medical, mental health and substance use histories to be able to form the best possible treatment plan. If you or the individual you are filling out this form for has insurance, this information will also help us make sure that insurance is able to cover as much of the costs of treatment as possible. 

It is especially important to have a comprehensive substance use history and prior medical treatments related to mental health and substance use disorders. Even if the use of some substances or treatments seems insignificant, it is important to include as much information as possible. 

We collect information on current or prior legal issues so our case managers will have all relevant information from the very beginning of treatment to best facilitate extraneous circumstances like probation and parole. 

If you are filling out this questionnaire for someone other than yourself, we ask you to be as thorough and accurate as possible. Please use the information of the individual who will be attending treatment. If you do not know specific information, or if you have any questions or concerns as you are filling out the questionnaire, please feel free to call us directly at (800) 213-0892

Any information submitted is transmitted through a secure connection and stored on HIPAA compliant servers. We take your privacy very seriously and are committed to making sure any personal information is entirely protected. If you want to read more about our privacy policy or how we handle your medical records, you can read our comprehensive privacy policy here.