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Lakeview Admission Application Form

We understand that seeking help is a significant and courageous step, whether for yourself, a client or patient, or a family member. Our team is committed to providing a supportive, confidential, and compassionate admissions process for all individuals who are ready to embark on their recovery journey.


Who Can Refer?

  • Self-Referral: If you feel that you need support in overcoming addiction or other challenges, you can directly apply yourself.

  • Professional Referral: Healthcare providers, counselors, social workers, and other professionals can refer their clients or patients who may benefit from our services.

  • Family Referral: Family members concerned about their loved one's well-being can also submit a referral on their behalf.



Confidentiality Assurance

We prioritize your privacy and are committed to maintaining the confidentiality of all applicants. Rest assured that any information you provide during this process will be handled with the utmost care and discretion, adhering to all relevant privacy laws and standards.

Person filling out the form:

Role

If someone other than the subject is filling out this form, please provide the following details:

Applicant Information

Birthday
Preferred Method of Contact:

Emergency Contact Information

Current Housing Status

Corrections Involvement

Are you currently involved with Corrections?
Yes
No

If yes, please specify:
Remand
Sentenced Pending Release
Drug Court
Parole

Additional Details

Do you have a criminal record
Yes
No

Basic Medical Information

Do you have any chronic medical conditions?
Yes
No
Are you currently taking any medications?
Yes
No

Substance Use History

Previous Treatment History

Have you attended a treatment program before?
Yes
No
If yes, please list:

Consent and Agreement

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