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Red Oak Recovery
Young Adult Rehab in North Carolina
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Dual Diagnosis Treatment
Alcohol Rehab Program
Heroin Rehab Program
Men’s Rehab Program
What We Treat
Grief Counseling
Co-Occurring Disorder Treatment
Disordered Eating Treatment
Mental Health Treatment
Anxiety Treatment Program
Depression Treatment Center
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Drug Addiction Treatment
Meth Addiction Treatment
Cocaine Addiction Treatment
Heroin Addiction Treatment
Xanax Addiction Treatment
Marijuana Addiction Treatment
Enrollment
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Referring Professionals
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Contact Us
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Careers
About Us
Treatment Plan
Therapeutic Outcome Study
Testimonials
Campus Team
Letter from Our Director
Leadership Team
Clinical Team
Operations Team
Holistic Services
Culinary Nutritional Arts
Administration
Medical Team
Enrollment and Marketing Team
What To Look For In A Treatment Center
Our Treatment Programs
Women’s Treatment Program
Women’s Substance Use Treatment
Adolescent Treatment Program
Addiction Therapy Services
Adventure Therapy
Behavioral Therapy
Nutritional Therapy
Experiential Therapy
Group Therapy
Trauma Therapy
Psychotherapy
Wilderness Therapy
Recovery Management
Family Services
Family Therapy
Family Therapy Program
Family Counseling
Clinical Rehabilitation
12 Step Addiction Recovery
Dual Diagnosis Treatment
Alcohol Rehab Program
Heroin Rehab Program
Men’s Rehab Program
What We Treat
Grief Counseling
Co-Occurring Disorder Treatment
Disordered Eating Treatment
Mental Health Treatment
Anxiety Treatment Program
Depression Treatment Center
Trauma Treatment
Family Program
Drug Addiction Treatment
Meth Addiction Treatment
Cocaine Addiction Treatment
Heroin Addiction Treatment
Xanax Addiction Treatment
Marijuana Addiction Treatment
Enrollment
Client Application Form
Insurance Policies
Insurance Verification
Referring Professionals
Blog
Contact Us
Photo Video Tour
Careers
Client Application Form
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Addiction Treatment Enrollment
Client Application Form
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Date Submitted
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Client Information
Applicant Name
*
Gender
*
Pronouns
*
DOB
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Height
*
Weight
*
Parent/Guardian/Spouse Information
Primary Parent/Guardian or Spouse Name
*
Relationship
*
Parent/Guardian or Spouse DOB
*
MM slash DD slash YYYY
Parent/Guardian or Spouse Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent/Guardian or Spouse – Mobile phone
*
Parent/Guardian or Spouse – Email
*
How did you first hear about Red Oak Recovery? Please include any referral source names and contact information:
*
Family Information
Is the applicant adopted?
*
Yes
No
Does the applicant have any siblings?
*
Yes
No
Please list all siblings and their ages:
*
Have the applicant's siblings struggled with mental health or substance use?
*
Yes
No
Please explain:
*
Were there any complications during birth mother's pregnancy or delivery?
*
Yes
No
Please explain:
*
Placement Information
What specific events precipitated your decision to seek treatment?
*
What are your specific goals for the applicant while receiving treatment?
*
What would you describe as the applicant's strengths? (intellectually, artistically, socially, physically, etc)
*
What would you describe as the applicant's weaknesses? (intellectually, artistically, socially, physically, etc)
*
Do you have any plans for future placement?
*
Treatment History
Outpatient Therapy or Programs, Residential or Inpatient Programs
Treatment Provider
*
Treatment Provider Location
*
Reason for placement/intervention and outcomes
*
Add Additional Treatment Providers?
*
Yes
No
Please include additional treatment provider name(s), location(s), and reason for placement and outcomes:
Psychological History
Please describe any major events the applicant has struggled with (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.), including the date the event occurred:
*
Describe the ways in which the applicant expresses anger
*
Has the applicant had any physical confrontations in the home or with others?
*
Yes
No
Please describe in detail including dates, persons involved, and circumstances that induced the event:
*
Has the applicant ever intentionally hurt themself?
*
Yes
No
Please describe in detail (include date, reason, what was used, where on the body the self-harm occurred, if medical attention was needed, how many times it occurred, and/or for how long):
*
Has the applicant ever had thoughts of suicide, made a plan, or attempted suicide?
*
Yes
No
Please describe in detail (specify date, reason, if thoughts are active or passive, manipulation, and/or general history):
*
Has the applicant ever run away?
*
Yes
No
Please describe (specify date, how long applicant ran away for and where, if the applicant had contacted you, etc.):
*
Does the applicant exhibit signs of anxiety, depression, mood swings, etc.?
*
Yes
No
Please describe in detail with examples and dates when behaviors were exhibited:
*
Does the applicant experience recurrent thoughts or repeated behaviors that they cannot control?
*
Yes
No
Please describe in detail, and include dates:
*
Does the applicant have a history of lying, stealing, vandalism, dealing drugs, and/or criminal activity?
Yes
No
Please describe in detail, and include dates:
*
Has the applicant ever been charged with or convicted of sexual assault?
*
Yes
No
Please include charge or conviction details, including type and approximate dates:
*
Does the applicant have a history of eating issues, current or past?
*
Yes
No
Please describe eating issues in detail, and include dates:
*
Does the applicant have problems with isolation?
*
Yes
No
Please describe problems with isolation in detail:
*
Does the applicant have any alcohol, substance abuse, and/or dependency-related issues?
*
Yes
No
Please describe alcohol, substance abuse, and/or dependency-related issues:
*
Does the applicant need detox prior to coming to Red Oak Recovery? If so, explain:
*
Has the applicant had any psychological testing?
*
Yes
No
Please describe testing (including date(s)/reason(s):
*
Have there been other addictive patterns (e.g. video games, TV, internet, sex, gambling)?
*
Yes
No
Please describe other addictive patterns:
*
Have there been legal problems?
*
Yes
No
Please list any charges, convictions, misdemeanors, felonies, probation and current legal status:
*
Is there family history of substance use or mental illness?
*
Yes
No
Please describe family mental illness or substance use history:
*
Medical Information
Applicant's most recent doctor and phone number:
*
Has the client experienced any recent/current illnesses or injuries? If so, what follow-up care is required?
*
Has the applicant ever had a seizure? If so, please provide dates and a detailed description of the event(s):
*
Has the applicant had any head injuries, loss of consciousness, or concussions? If so, please provide dates and a detailed description of the event(s):
*
Is the applicant currently taking any prescribed or over-the-counter medications? If so, provide details below.
Are there any known side effects of the medication(s)? If so, please describe:
*
Please describe previous history of medication(s); have any medications worked/not worked in the past?
*
Has the applicant struggled with medication compliance, especially in a treatment program? Please describe:
*
Is the applicant currently taking any vitamins or supplements? If so, please describe:
*
Describe any medical/physical information that might limit or impair tolerance for physical activity:
*
Does the applicant have any dietary restrictions/preferences? If so, please describe, including the reaction:
*
Does the applicant have allergies or asthma? If so, provide details below:
*
Does the applicant carry an inhaler or epinephrine pen? If so, please list name/type of inhaler:
*
Has the applicant ever been hospitalized for allergies/asthma? If so, please describe (include date/reason):
*
List of Medical Conditions / Abnormalities:
Does the applicant currently have or ever had any of the following?
Allergies
Anaphylactic shock
Anemia
Ankle problems
Anorexia/bulimia
Appendicitis
Arm problems
Arthritis
Asthma
Back problems
Bedwetting
Bladder/kidney problems or infection
Bleeding disorder
Bone condition
Bowel problems
Broken bones
Cancer
Chest pains
Chronic cough
Circulation issues
Colds (frequent)
Constipation
Cysts/tumors
Dermatitis
Diabetes I/II
Diarrhea
Difficulty walking or lifting
Ear infections
Endocrine problems
Excessive sweating
Fainting/dizziness
Family history of heart disease
Foot problems
Frequent colds/sore throats
Frequent heartburn
Frequent muscle cramps
Frequent shortness of breath
Frostbite
Gas/bloating
HIV/AIDS
Head traumas
Headaches/migraines
Hearing impairment
Heart problems/murmurs
Hepatitis A/B/C
Hernia
High blood pressure
Hypoglycemia
Intolerance to cold
Intolerance to heat/overheats easily
Irregular heartbeat
Joint injuries
Kidney problems
Knee problems
Leg problems
Liver problems
Lung infections
Medical equipment or devices
Meningitis
Menstrual problems/ heavy bleeding
Mononucleosis
Motion sickness
Obesity
Other
PMS - severe symptoms
Pneumonia/bronchitis
Pregnancy
Recurrent injury/surgery
STDs
Scoliosis
Seizures/epilepsy
Shoulder problems
Skin diseases/problems
Sleepwalking
TB - Positive test
TB - Recent exposure
TB - Tuberculosis
Thyroid problems
Ulcers
Unexpected weight loss
Please describe any checked item in full detail, including dates, symptoms, and thorough explanation:
*
*
By checking this box, I am attesting that all of the above medical conditions have been reviewed and that the applicant has never experienced any of the boxes left unchecked.
Please list any pertinent medical history in the applicant’s family:
*
Insurance Information
My insurance information has already been submitted to the Admissions Team.
*
Yes
No
Primary Insurance Company
*
Group number
*
Policy number
*
Policyholder's name
*
Policyholder's DOB
*
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CALL NOW AT 828.382.9699
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