Online application

Permanent Address:*

If yes, please list the organization you affiliate with:

Whom is your support system?

What do you do to manage your spirituality?

What happened in your life to lead you to seek treatment now (precipitating events)?

Why is Corner Canyon the program you are most interested in attending for RTC treatment? Please be sure
to include specific aspects of the program that you are interested in.

Please describe your current living environment.

Please describe your relationships with your family members.

Please describe your some of your personal interests.

Please describe some of your personal strengths.

Do you have a primary care physician, psychiatrist, and/or therapist? (Yes/No)
YesNo

If yes, please list them:

Are you currently on any medications, vitamins, and/or supplements? (Yes/No)
YesNo

If yes, please list them below and include the dosage of each and the reason for taking the medication and/or supplement

Do you find the medication beneficial? (Yes/No)
YesNo

How often/frequency do you take the medication?

How long have you been prescribed this medication for?

Do you have any allergies? (Yes/No)
YesNo

If yes, please explain.

Have you ever taken any medication that you have had a negative reaction to? (Yes/No)
YesNo

If yes, please describe in detail

Do you have any symptoms of concerns to address with the medical staff? (Yes/No)
YesNo

If yes, please explain.

Are there any health concerns you have that would keep you from participating in treatment and/or physical activities? (Yes/No)
YesNo

If yes, please explain

Corner Canyon Health Centers has two(2) flights of stairs in the home. Are you able to move up and down the stairs safely and easily? (Yes/No)
YesNo

How far are you able to walk and/or run before getting winded?

Have you been hospitalized in the past year for any medical concerns? (Yes/No)
YesNo

If yes, please provide information in detail and include dates:

Do you have any dental problems or concerns? (Yes/No)
YesNo

If yes, please explain:

Any history of blackouts, seizures, or DT's? (Yes/No)
YesNo

If yes, please explain:

Any active easting disorders (i.e. restricting, over-eating, purging) or any history of eating disorders? (Yes/No)
YesNo

If yes, please explain:

Do you have any dietary restrictions? (Yes/No)
YesNo

If yes, please explain:

Have you struggled to maintain daily activities such as showering/bathing, getting dressed, grooming, oral care, eating, cooking, medication management, housework, laundry, driving, or managing finances? (Yes/No)
YesNo

If yes, please explain which daily activities you are struggling with and in what ways you are unable to maintain acceptable standards

Are you currently experiencing chronic pain? (Yes/No)
YesNo

If yes, please rate your chronic pain level on a scale of 1-10 with 10 being the highest level of pain

Have you ever used: alcohol, marijuana, amphetamines, cocaine, crack, heroin, oxy/roxys, percocets, xanax, klonopin, or other drug outside the use prescribed by a doctor
YesNo

If yes, please list what drug, first use, last use, frequency/route, amount and use pattern over the last 12 months:

Do you use tobacco products of any kind?
YesNo

If yes, what kind of tobacco products?

What does your drug history progression look like with your DOC?

Have you ever been to a treatment facility for mental health in the past? (Yes/No)
YesNo

If yes, what has occurred since you were discharged that has led you to seeking treatment again?

What is the longest you were able to remain functional, free from problematic behaviors, and/or be able to successfully manage mental health symptoms?

Please list any treatment facilities you've been to previously and include the dates, reason for treatment, the precipitating events leading to treatment, the duration you were in treatment, and your outcome comments.

Have you had any psychological testing completed within the last year? (Yes/No)
YesNo

If yes, when and where was it completed?

Have you been to a treatment facility for substance abuse in the past? (Yes/No)
YesNo

If yes, what has occurred since you were discharged that has led you to seeking treatment again?

What is the longest you were able to remain sober?

Please list any treatment facilities you've been to previously and include the dates, reason for treatment, the precipitating events leading to treatment, the duration you were in treatment, and your outcome comments.

Do you currently have any experience with any recovery community? (Yes/No)
YesNo

If yes, please explain:

Do you have a sponsor? (Yes/No)
YesNo

Do you have a history of any other addictions or maladaptive coping? This may include one or more of the following: gambling, cutting/burning, self-harm, internet, pornography, sex, binging/purging/restricting, gaming, or sports (Yes/No)
YesNo

If yes, please explain:

Have you experienced any traumatic events in your life? (Yes/No)
YesNo

If yes, have you experienced any of the following
Intense feels of distress when reminded of a tragic eventExtreme physical reactions to reminders of trauma such as nausea, sweating or a pounding heartInvasive, upsetting memories of a tragedyFlashbacks (feeling like the trauma is happening again)Nightmares of either frightening things or of the eventLoss of interest in life and daily activitiesFeeling emotionally numb and detached from other peopleSense of not leading a normal life (not having a positive outlook of your future)Avoiding certain activities, feelings, thoughts or places that remind you of the tragedyDifficulty remembering important aspects of tragic eventNegative feelings about self and the worldDifficulty feeling positiveDifficulty sleeping or staying asleepHeightened startle responseEngaging in destructive or risky behavior

Do you have any previous diagnosis for mental health? This may include one or more of the following: depression, anxiety, bipolar, or schizophrenia. (Yes/No)
YesNo

If yes, please explain:

Do you have a previous DID diagnosis or a history of DID? If yes, a phone call with our clinical director or assistant clinical director must be completed prior to making a decision on the application as part of our pre-screening process. (Yes/No)
YesNo

Have you ever taken medications for any substance abuse or mental health diagnosis?
(Yes/No)
YesNo

If yes, please indicate the diagnosis as well as the medications that were taken for each diagnosis.

Does anyone in your family have a history of substance use or mental health diagnosis?
(Yes/No)
YesNo

If yes, please indicate who and what substances or diagnosis.

Are you currently experiencing any of the following (check all the apply):
Work/School ProblemsFamily FunctioningPersonality ChangesStays out all nightInability to Manage SelfIsolatingPrevious Treatment EpisodesSad or Angry OftenViolent OutburstsExplosive OutburstsInability to Think ClearlySevere Mood SwingsDangerous Affiliations due to Drug UsePutting Yourself in Risky SituationsStealing for Drug/Alcohol UseHx Hallucinations

Do you feel you are experiencing any symptoms of depression? (Yes/No)
YesNo

If yes, please describe the quality of your depressive episodes including the frequency, duration, the direct impact on your daily life and the date of your most recent episode.

Do you feel you are experiencing any symptoms of anxiety? (Yes/No)
YesNo

If yes, please describe the quality of your depressive episodes including the frequency, duration, the direct impact on your daily life and the date of your most recent episode.

Do you ever have panic attacks? (Yes/No)
YesNo

If yes, please describe the quality of your panic attacks including the frequency, duration, the direct impact on your daily life and the date of your most recent episode.

Do you have a history of hallucinations? Either auditory, visual or tactile? (Yes/No)
YesNo

If yes, please explain.

Do you have a history of paranoia? (Yes/No)
YesNo

If yes, please indicate known causes of paranoia (i.e. drugs, mental health diagnosis, etc.)

Are you currently experiencing any detox symptoms? (i.e. shakes, anxiety, sweats, cravings, nausea, body aches, etc.) (Yes/No)
YesNo

If yes, please explain.

Please rate your cravings on a scale of 1-10.

Are there any coping skills you find beneficial when you are struggling? (Yes/No)
YesNo

If yes, please explain.

Please list any known triggers or situations that can be triggering for you.

Are there any aspects of your daily life that you find too stressful or challenging to handle? (Yes/No)
YesNo

If yes, please explain.

Do you currently have or have a history of suicidal thoughts? (Yes/No)
YesNo

1) Have you ever wished you were dead or wished you could go to sleep and not wake up? (Yes/No)
YesNo

2) Have you had any actual thoughts of killing yourself? (Yes/No)
YesNo

3) Have you been thinking about how you might kill yourself? (Yes/No)
YesNo

4) Have you had these thoughts and had some intention of acting on them? (Yes/No)
YesNo

5A) Have you started to work out or have worked out the details of how to kill yourself? (Yes/No)
YesNo

5B) Do you intend to carry out this plan? (Yes/No)
YesNo

6A) Have you ever done anything, started to do anything, or prepared to do anything to end your life? (Yes/No)
YesNo

6B) If yes to question 6a, how long ago did you do any of these?

Do you have any history of homicidal thoughts or ideation? (Yes/No)
YesNo

If yes, do you have a plan? (Yes/No)
YesNo

Any legal history? (Yes/No)
YesNo

If yes, please explain.

Any current or pending legal charges? (Yes/No)
YesNo

Any pending court dates? (Yes/No)
YesNo

Any history of domestic violence or aggressive behavior? (Yes/No)
YesNo

If yes, please explain.

What are your plans for aftercare or continued treatment post-residential?

What is your motivation for your recovery at this time?

Have you had close physical contact with someone who has traveled to China, Iran, South Korea, Italy, Japan, Macau, Taiwan, or Europe in the past 30 days? (Yes/No)
YesNo

Do you know or suspect to have been in close physical contact with someone who has COVID-19? (Yes/No)
YesNo

Do you have any symptoms of illness? This may include one or more of the following: persistent cough, chest pains, shortness of breath, fever, fatigue, nasal congestion, runny nose, sore throat, diarrhea, nausea, etc. (Yes/No)
YesNo

Have you been following social distancing guidelines and self-quarantine/self-isolation? (Yes/No)
YesNo

If so, where have you been for isolation and for how long?

Have you received the COVID-19 vaccine? (Yes/No)
YesNo

If so, please list the manufacturer and date(s) of doses.

Please list any needs you may have that have not been addressed in this application.