Turning Point Center Application

I understand that I am submitting an application for Turning Point Center, a residential detox and substance use treatment facility. This is not outpatient treatment.*

Have you been seen at LifeSpring in the last three years for any reason?

Name

First Last

Phone*

Alternate Phone Number of Someone Who Can Usually Get in Touch With You

Address*

Street Address City State / Province / Region ZIP / Postal Code Country

County of Residence*

Date of Birth

Gender Identity*

Race*

Ethnicity*

Sexual Orientation*

Marital Status*

Insurance Company

Insurance Member ID

Name and Date of Birth of Policy Holder

Total Household (Family Only) Income Per Year

Total Number of People In your Household (Family Only)

Veteran Status

Primary Care Provider

First Last

Primary Care Provider Phone

Who Referred You to Turning Point Center?

In the Last 30 Days, Have You Been Arrested?*

If Yes, How Many Times in the Last 30 Days?

Are You on Probation or Parole?*

If Yes, in What County?

Do You Have Any Pending Court Dates?

If Yes, When and Where?

Are You a Registered Sex Offender?*

Do You Have Any Children?*

If Yes, How Many?

Do They Live With You?

Is DCS (Department of Child Services) Involved?

What County?

What Is Your Highest Level of Education?*

Have You Received Prior Substance Abuse Treatment?*

If Yes, What Type?

Where Did You Receive Prior Treatment?

Are You an IV User?*

Do You or Have You Shared Needles?*

Substance Used	Date Last Used	How Much? How Often?	Duration of Use

Medication Name	Dosage	Reason for Taking	Prescribing Doctor

Step 1 of 3

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