APPLICATION | The Mountain West Co

Initial Contact Information

Tell us who is filling out the application and how we can contact them.

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

What is your relationship to the patient?

Patient Information

Tell us who the application is for and how we can contact them.

Patient First Name

Patient Last Name

Patient Date of Birth

Patient Email

Patient Mobile Phone

Patient Work Phone

Patient Home Phone

Patient SSN

For identity verification (if applicable). This can be left blank if unknown.

Patient is experiencing homelessness

Patient Street Address

Patient City

Patient State

Patient Zip

Patient sex assigned at birth

Patient Marital Status

Patient Race

Insurance Information

Provide insurance or payment information so our team can verify coverage.

Patient Insurance Type

Member ID

Patient Relationship to Subscriber

Substance Use History & Other Info

Help us to understand current substance use and any immediate safety considerations, along with other pertinent info.

Are you required to register as a sex offender in the state of Colorado?

Have you ever been convicted of arson?

Do you agree to attend and participate in all required groups, adhere to house curfews, follow program guidelines, and be working or seeking work immediately upon joining the program?

What led you to contact Mountain West?

What is your primary substance of choice?

What is your secondary substance of choice? (optional)

Select “None” if not applicable.

What is your third substance of choice? (optional)

Select “None” if not applicable.

Are you experiencing withdrawals?

Do you have a history of DTs (Delirium Tremens)?

Do you have a history of seizures?

Do you have a history of blackouts?

Health & Treatment History

Share relevant medical, medication, and treatment history.

Do you have any current or past chronic health conditions?

Do you have any past or current mental health diagnoses?

Are you currently taking any medications?

Are you or could you possibly be pregnant?

Have you been hospitalized recently?

Have you been in substance use treatment in the last six months?

Have you been in sober living before?

Are you able to ambulate (walk around) without assistance and without the use of devices?

Final Review & Consent

Please review the final questions below and confirm each acknowledgment before submitting your application.

Are you currently on parole or probation?

Are you required to take monitored UAs?

Do you identify as trans or non-binary?

What is your gender identity?

What is your sexual orientation?

Are you currently employed?

Do you work with any outside social work agencies?

Our program is intended for individuals actively seeking employment, do you understand this?

Do you intend to file for Social Security disability in the next 60 days?

Are you able to work 40 hours per week?

Mountain West is not responsible for resident transportation or bus passes for its residents. Do you understand that you will be responsible for your own transportation while a resident at Mountain West?

Do you understand that if you do not honor the terms of the program you can be asked to leave without notice? (You are expected to be seeking employment, meeting with case management, being productive, respecting peers/staff., etc.)

Which MW location are you applying for?

JOIN US
MOUNTAIN WEST APPLICATION

Apply for treatment with clarity and confidence.

Initial Contact Information

Patient Information

Insurance Information

Substance Use History & Other Info

Health & Treatment History

Final Review & Consent

Application Submitted

Submitting your application securely

Submitting your application…

JOIN USMOUNTAIN WEST APPLICATION

Apply for treatment with clarity and confidence.

Initial Contact Information

Patient Information

Insurance Information

Substance Use History & Other Info

Health & Treatment History

Final Review & Consent

Required Acknowledgments

Application Submitted

Submitting your application securely

JOIN US
MOUNTAIN WEST APPLICATION