Online Admissions Form
Potential Clients Name
*
First Name
Last Name
DOB:
*
Diagnosis:
*
Name of person completing this application:
*
Your relationship to Client:
*
Your Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Person completing application's Email
example@example.com
Does Applicant Have:
Legal Guardian
Power of Attorney
Other representative of any kind
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Covid 19 vaccinated?
*
Covid 19 Boostered?
*
Reason Applicant is seeking residential care. Include current living situation:
*
If Applicant has a history of: Self Harm, Violence Sexual Promiscuity Substance Abuse Criminal Behavior or other high risk behaviors
Please Explain
Does applicant have any allergies, medical issues, or other physical wellness concerns?
Date of last physical:
Current PCP and address:
Current psychiatrist and contact information:
Person(s) financially responsible for applicants care
*
Averte is a private pay facility
How long do you anticipate being in treatment?
*
How did you hear about Averte? Did Someone Refer you?
*
Submit
Should be Empty: