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The Willows at Red Oak
Addiction Treatment for Women in North Carolina
About Us
Letter from Our Director
Leadership Team
Treatment Team
Medical and Holistic Services
Enrollment and Marketing Team
Outcome Study
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Womens Recovery Center
Our Men’s Treatment Program
Our Adolescent Treatment Program
Women’s Trauma-Informed Treatment Center
Holistic Healing
Long Term Drug Rehab Center
12 Step Program
Primary Treatment Center
Disordered Eating Support
Substance Use Treatment Center
Women’s Drug Addiction Treatment Program
Women’s Alcohol Addiction Treatment Program
Heroin Addiction Treatment Program
Opioid Addiction Treatment Program
Prescription Drug Addiction Treatment Program
Relapse Prevention
Coping Skills For Women
Women’s Treatment Center
Addiction Therapy Services
Cognitive Behavioral Therapy Program
Psychotherapy Program
Trauma Therapy Program
Group Therapy Program
Individual Therapy Program
Family Therapy Program
EMDR Therapy Program
Rational Emotive Behavioral Therapy
Experiential Therapy Program
Recreational Therapy Program
Yoga Therapy Program
Nutritional Therapy Program
Recovery Management
Dual Diagnosis
Depression Treatment Center
Anxiety Treatment Center
PTSD Trauma Treatment
Enrollment
Client Application Form
Insurance Policies
Insurance Verification
Referring Professionals
Our Blog
Careers
Contact
Get Help For A Loved One
About Us
Letter from Our Director
Leadership Team
Treatment Team
Medical and Holistic Services
Enrollment and Marketing Team
Outcome Study
Alumni Program
Womens Recovery Center
Our Men’s Treatment Program
Our Adolescent Treatment Program
Women’s Trauma-Informed Treatment Center
Holistic Healing
Long Term Drug Rehab Center
12 Step Program
Primary Treatment Center
Disordered Eating Support
Substance Use Treatment Center
Women’s Drug Addiction Treatment Program
Women’s Alcohol Addiction Treatment Program
Heroin Addiction Treatment Program
Opioid Addiction Treatment Program
Prescription Drug Addiction Treatment Program
Relapse Prevention
Coping Skills For Women
Women’s Treatment Center
Addiction Therapy Services
Cognitive Behavioral Therapy Program
Psychotherapy Program
Trauma Therapy Program
Group Therapy Program
Individual Therapy Program
Family Therapy Program
EMDR Therapy Program
Rational Emotive Behavioral Therapy
Experiential Therapy Program
Recreational Therapy Program
Yoga Therapy Program
Nutritional Therapy Program
Recovery Management
Dual Diagnosis
Depression Treatment Center
Anxiety Treatment Center
PTSD Trauma Treatment
Enrollment
Client Application Form
Insurance Policies
Insurance Verification
Referring Professionals
Our Blog
Careers
Contact
Get Help For A Loved One
Client Application Form
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Enrollment
Client Application Form
BEGIN YOUR JOURNEY WITH
THE WILLOWS TODAY!
Contact Us
Call Now 855.773.0614
Step
1
of
8
12%
Date Submitted
*
MM slash DD slash YYYY
Client Information
Name
*
Gender
*
Pronouns
*
DOB
*
MM slash DD slash YYYY
SSN
*
Expect to enroll
*
MM slash DD slash YYYY
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
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Kansas
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Louisiana
Maine
Maryland
Massachusetts
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New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Country
*
Mobile phone
*
Email
*
Ethnicity
*
Height
*
Weight
*
Eye Color
*
Hair Color
*
Shoe Size
*
Shirt Size
*
Waist
*
School Grade
*
Religious Preference
*
Is the applicant adopted?
*
Yes
No
Parent/Guardian/Sponsor Information
PRIMARY – Name
*
PRIMARY – Relationship
*
PRIMARY – Sponsor
*
Yes
No
PRIMARY – Legal custody
*
Yes
No
PRIMARY – Physical custody
*
Yes
No
PRIMARY – Emergency contact
*
Yes
No
PRIMARY – Parent guardian
*
Yes
No
PRIMARY – DOB
*
MM slash DD slash YYYY
PRIMARY – SSN
*
PRIMARY – Address
*
PRIMARY – City
*
PRIMARY – State
*
PRIMARY – Zip
*
PRIMARY – Mobile phone
*
PRIMARY – Email
*
PRIMARY – Home fax
*
PRIMARY – Job title
*
PRIMARY – Employer
*
PRIMARY – Work email
*
SECONDARY - Name
SECONDARY - Relationship
SECONDARY - Sponsor
Yes
No
SECONDARY - Legal custody
Yes
No
SECONDARY - Physical custody
Yes
No
SECONDARY - Emergency contact
Yes
No
SECONDARY - Parent guardian
Yes
No
SECONDARY - DOB
SECONDARY - SSN
SECONDARY - Address
SECONDARY - City
SECONDARY - State
SECONDARY - Zip
SECONDARY - Mobile phone
SECONDARY - Home email
SECONDARY - Home Fax
How did you first hear about Red Oak Recovery?
*
If you used a search engine, what search terms were used?
*
Please give the name(s) of the referral source including phone, fax number and email:
*
Reason for referral
*
Placement Information
What specific events precipitated your decision to seek treatment?
*
What are your specific goals for the applicant while receiving treatment?
*
What would you describe as the applicant's strengths? (intellectually, artistically, socially, physically, etc)
*
What would you describe as the applicant's weaknesses? (intellectually, artistically, socially, physically, etc)
*
Describe the applicant's experience with the outdoors and other physical activities
*
Do you have any plans for future placement?
*
Placement/ Intervention History
Placement/intervention 1
*
Placement/intervention 1 - Contact?
*
No
Yes
Placement/intervention 1 - Location
*
Placement/intervention 1 - Dates
*
Placement/intervention 1 - Provider
*
Reason for placement/intervention and outcomes
*
Placement/intervention 2
Placement/intervention 2 - Can we contact?
No
Yes
Placement/intervention 2 - Location
Placement/intervention 2 - Dates
Placement/intervention 2 - Provider
Reason for placement/intervention and outcomes
Placement/intervention 3
Placement/intervention 3 - Can we contact?
No
Yes
Placement/intervention 3 - Location
Placement/intervention 3 - Dates
Placement/intervention 3 - Provider
Reason for placement/intervention and outcomes
Has the applicant had any psychological testing? If yes, please describe (include date/reason):
*
Note: Please fax/email/mail all previous testing from the last 3 years as part of this application.
Please describe anything of note regarding ethnicity, race, religion, and nationality:
*
Sexual Orientation
*
Psychological History
Please describe any major events the applicant has struggled with (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.), including the date the event occurred:
*
Describe the ways in which the applicant expresses anger
*
Has the applicant had any physical confrontations in the home or with others? If yes, please describe in detail including dates, persons involved, and circumstances that induced the event:
*
Has the applicant ever intentionally hurt themself? If yes, please describe in detail (include date, reason, what was used, where on the body the self-harm occurred, if medical attention was needed, how many times it occurred, and/or for how long):
*
Has the applicant ever run away? If yes, please describe (specify date, how long applicant ran away for and where, if the applicant had contacted you, etc.):
*
Has the applicant ever had thoughts of suicide, made a plan, or attempted suicide? If yes, please describe in detail (specify date, reason, if thoughts are active or passive, manipulation, and/or general history):
*
Please describe any risky, aggressive or inappropriate sexual behaviors of the client (promiscuity, unprotected sex, perpetrating, deviance, etc.):
Does the applicant exhibit signs of anxiety, depression, mood swings, etc.? If yes, please describe in detail with examples and dates when behaviors were exhibited:
*
Does the applicant experience recurrent thoughts or repeated behaviors that they cannot control? If yes, please describe in detail, and include dates:
*
Does the applicant have a history of lying, stealing, vandalism, dealing drugs, and/or criminal activity? If yes, please describe in detail, and include dates:
*
Please check all the unusual behaviors that apply to the applicant:
Delusions
Hallucinations
Paranoid thinking
Nightmares
Tics
Stuttering
Bedwetting
Head banging
Please describe in detail, including dates:
Does the applicant have a history of eating issues, current or past? If yes, describe in detail, and include dates:
*
Does the applicant have problems with isolation? If yes, please describe in detail:
*
Does the applicant have any alcohol, substance abuse, and/or dependency-related issues?
*
Substance usage
*
Does the applicant need detox prior to coming to Red Oak Recovery? If so, explain:
*
Has there been a family history of drug or alcohol abuse? If so, please describe (include who/relationship, problem area, current status):
*
Have there been other addictive patterns (e.g. video games, TV, internet, sex, gambling)? If so, please describe:
*
Have there been any legal problems? If so, please list any charges, convictions, misdemeanors, felonies, probation and current legal status:
*
Does the applicant have a history of starting fires? If yes, please describe in detail:
Is there a family history of mental illness (e.g. depression, anxiety, etc.)? If so, please describe (include who/ relationship, problem area, current status):
*
Medical Information
Family Doctor
*
Phone
*
Family Dentist
*
Has the applicant ever had a seizure? If so, please provide dates and a detailed description of the event(s):
*
Phone
*
Does the applicant wear glasses or contacts?
*
Date of last physical
*
MM slash DD slash YYYY
Doctor
*
Reason
*
Has the applicant had any head injuries, loss of consciousness, or concussions? If so, please provide dates and a detailed description of the event(s):
*
Is the applicant currently taking any prescribed or over-the-counter medications? If so, provide details below.
Are there any known side effects of the medication(s)? If so, please describe:
*
Please describe previous history of medication(s), including the name of medication, dosage, reason, and prescribing physician:
*
Is the applicant currently taking any vitamins or supplements? If so, please describe:
*
Does the applicant currently get exercise? If so, please describe:
*
Describe any pertinent medical/physical information that might inhibit physical activity:
*
Does the applicant have any dietary restrictions? If so, please describe:
*
Does the applicant have any dietary preferences? If so, please describe:
*
Does the applicant currently have or ever had any of the following?
Allergies
Anaphylactic shock
Anemia
Ankle problems
Anorexia/bulimia
Appendicitis
Arm problems
Arthritis
Asthma
Back problems
Bedwetting
Bladder/kidney problems or infection
Bleeding disorder
Bone condition
Bowel problems
Broken bones
Cancer
Chest pains
Chronic cough
Circulation issues
Colds (frequent)
Constipation
Cysts/tumors
Dermatitis
Diabetes I/II
Diarrhea
Difficulty walking or lifting
Ear infections
Endocrine problems
Excessive sweating
Fainting/dizziness
Family history of heart disease
Foot problems
Frequent colds/sore throats
Frequent heartburn
Frequent muscle cramps
Frequent shortness of breath
Frostbite
Gas/bloating
HIV/AIDS
Head traumas
Headaches/migraines
Hearing impairment
Heart problems/murmurs
Hepatitis A/B/C
Hernia
High blood pressure
Hypoglycemia
Intolerance to cold
Intolerance to heat/overheats easily
Irregular heartbeat
Joint injuries
Kidney problems
Knee problems
Leg problems
Liver problems
Lung infections
Medical equipment or devices
Meningitis
Menstrual problems/ heavy bleeding
Mononucleosis
Motion sickness
Obesity
Other
PMS - severe symptoms
Pneumonia/bronchitis
Pregnancy
Recurrent injury/surgery
STDs
Scoliosis
Seizures/epilepsy
Shoulder problems
Skin diseases/problems
Sleepwalking
TB - Positive test
TB - Recent exposure
TB - Tuberculosis
Thyroid problems
Ulcers
Unexpected weight loss
*
By checking this box, I am attesting that all of the above medical conditions have been reviewed and that the applicant has never experienced any of the boxes left unchecked.
Please describe any checked item in full detail, including dates, symptoms, and thorough explanation:
*
Is the client up to date on immunizations?
*
Yes
No
Date of Last Immunization
*
MM slash DD slash YYYY
Tetanus/Diptheria
Measles/Mumps/Rubella
Hepatitis B
Polio
Does the applicant have allergies or asthma? If so, provide details below:
*
Does the applicant carry an inhaler or epinephrine pen? If so, please list name/type of inhaler:
*
Has the applicant ever been hospitalized for allergies/asthma? If so, please describe (include date/reason):
*
Please list any pertinent medical history in the applicant’s family:
*
Insurance Information
Primary Insurance Company
*
Address
*
Benefits Phone
*
Group number
*
Policy number
*
Policyholder's name
*
Employer
*
DOB
*
MM slash DD slash YYYY
SSN
*
Secondary insurance company
Address
Benefits phone
Group number
Policy number
Policyholder's name
Employer
DOB
MM slash DD slash YYYY
SSN
Parents Marital Status (Combined)
Placement/Intervention 1 (Combined)
Placement/Intervention 2 (Combined)
Placement/Intervention 3 (Combined)
Primary Relationship (Combined)
Secondary Relationship (Combined)
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