Admissions Form

 

Before you fill-out this questionnaire, please be sure that you:

  1. have briefly talked with Admissions point person,

  2. have read the Exclusionary Criteria for Admission found on our website

  3. understand that clearance from your primary care doctor is required,

  4. understand that a brief admissions interview and mental health assessment by one of our consulting mental health professionals follows this submission of this questionnaire,

  5. understand that Admissions is triaged and no admissions date is guaranteed,

  6. understand that you have 36 hours to confirm your participation in the program once a date has been sent to you, and

  7. have paid the Admission Processing fee of Php10,000.

Admissions checklist:

  1. Phone Interview

  2. Admissions Questionnaire

  3. Medical Clearance

  4. Mental Health Evaluation

  5. Confidentiality and Non-Disclosure Agreement

  6. Safety Agreement (non-harm)

  7. Notice of Privacy Practices

  8. Admissions Processing Fee

Please take a few moments to complete this form.

Please tell us about yourself, your needs, and your goals, as well as other details to help us customize your program. Please be specific.

Name *
Name
Home Phone *
Home Phone
Work Phone
Work Phone
Emergency Contact Number *
Emergency Contact Number
If necessary, may we contact your Emergency Contact? *
Will this be your first time in residential care? *
Long-term Hospital Stay? Rehab/Recovery Facility? Wellness/Spa?
Presenting Problem
Please check all of the symptoms in the following list that you are currently experiencing: *
Health History
Please name the medication, what it was treating, dosage, and duration
If yes, please describe.
Method of payment: *
 
Udo Goebel