APPLICATION | The Mountain West Co

1.) Contact Information for the Person filling out this application

Please enter the first name of the person filling out this application

Please enter the last name of the person filling out this application

Please enter the email of the person filling out this application

Please enter a good contact number for the person filling out this application

2.) Information About the Patient

Patient's first name

Patient's last name

Patient's date of birth required

Patient's mobile phone number

Patient's work phone number

Patient's home phone number

Patient's SSN

Patient's email

Patient is Homeless

Patient street address

Patient city

Patient ZIP

3.) Insurance Information

Member Insurance ID

Policy holder's first name

Policy holder's last name

Poliy holder's address

Policy holder city

Policy holder ZIP

Policy holder DOB

Policy holder's SSN

4) Additional Questions

What led you to contact Mountain West?

Please describe the withdrawal symptoms

Please explain your history of DTs

Please explain your history of seizures

Please explain your history of blackouts

5) Medical & Mental Health

Please explain your chronic health conditions

Please explain your mental health diagnoses

Please list medications and dosages

Important: Medications We Cannot Accept
We are unable to accept medications in the following categories:

Stimulants
Benzodiazepines
Barbiturates
Narcotics / Opioids - MAT Medications (ex: Suboxone, Methadone) ARE allowed.

If you are currently prescribed one of these, our medical provider will review your case. Clients entering treatment on a restricted medication may be asked to taper under medical supervision or transition to non-controlled alternatives where appropriate.

Explain recent hospitalizations (Where, What for):

Explain where you were, when, and the outcome of treatment (successful, left early, etc.):

Explain where you were, when, and the outcome of your time there:

6) Legal & Additional Information

Please list the county and PO:

Please list any social service or support agencies you are working with. This could include case managers, housing programs, probation officers, child welfare, or other community support services.

By checking this box, I am stating that all information provided has been truthful, and if it is found that I was not truthful with the information provided on this form it could be grounds or immediate discharge from the program.

By submitting this form, I acknowledge that my personal information will be processed in accordance with the Privacy Policy.View Privacy Policy

I understand that I am that I am entering a outpatient substance use treatment program thta provides revery housing. A clinician will determine that most appropriate level of care based upon an assement that will be conducted on the day of intake. I agree to follow the requirements of the level of care I am placed in. This includes attending required groups, following program rules, and participating fully in treatment.

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Please allow 24–48 hours for us to review your application and respond.

Thank you!

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