First Name

Last Name

Phone *

Email

Date of birth *

Age: *

Name of Organization / Referral *

Are you a convicted Felon? *

Are you currently on parole? *

Are you register as a sex offender? *

Are you US Citizen? *

Processed Migrant? *

Legal Resident? *

Medical Common Symptoms/Diagnosis? *

Date of last treatment *

Are you currently in treatment? *

Have you ever been baker acted before? *

Any health or medical conditions? *

Any recent hospitalizations? *

Are you taking any medications? *

Which gender do you identify as? *

Emergency Contact Name *

Emergency Contact Phone Number

Emergency Contact Address *

Emergency Contact Relationship *

I confirm that all information provided is true and correct. By providing my phone number, I agree to receive text or call from the business.