CONFIDENTIAL
Residential
Treatment Application
4066 Dunnica St. Louis, Missouri 63118 Phone: 314-833-6155FAX: 314-833-6159
ADVANCE@PFH takes a holistic strengths-based approach tailoring therapeutic interventions to individual strengths, needs, abilities, and preferences. ADVANCE@PFH provides a full continuum of care for substance use and co-occurring disorders for young adults’ ages 18-26 years old.
You may be asking, “Why do I need to apply for treatment?” ADVANCE@PFH strives to turn no one away. However, treatment funds for the uninsured are limited. You can help us expedite the application and admission process by answering all questions to the best of your ability and sending the completed application back to us as soon as possible.
ADVANCE@PFH is committed to doing our best to ensure prompt access to treatment prioritizing admissions of applicants based on need and residential bed availability.
Reaching out for help takes courage; no matter the life circumstances surrounding your investment in treatment at this time; participation in ADVANCE@PFH is strictly voluntary.
Should it be determined that ADVANCE@PFH is not a good fit for you; our Staff will work with you to find an appropriate alternate treatment program to help meet your needs.
What you will need to complete the application process:
- ADVANCE@PFH Participant Handbook
- Our Handbook will provide a basic awareness of treatment expectations.
- A willingness to participate in structured therapeutic activities is a key aspect of maximizing the benefit of treatment for you as well as for other program participants.
- Completed Application
- Submit to or Fax to: 314-833-6159.
- Verification of Missouri Residency - Photo Copy of ID
- This is necessary as funds available to assist in paying for treatment services are currently limited to State of Missouri Residents.
Upon receipt of your application, you will receive a phone call and/or email to schedule a phone or in-person Screeningif this was not completed upon initial contact.
Thank you for your interest in ADVANCE@PFH and if you have any questions feel free to email us at or call us at 314-833-6155.
Congratulations on taking the first step toward Recovery!
Shelley Stretch
Clinical Supervisor
Applicant Information
;
(Last Name) (First Name) (MI) (NickName OR Preferred Name)
(Primary Phone#) (Secondary Phone#) (Email Address) (Birth Date MM/DD/YY)
(Street Address)(City) (State) (Zip Code)
I give permission for staff to contact me by: Phone Email
Emergency Contact Information
(Last Name) (First Name) (Relationship to Applicant)
Yes No
(Primary Phone#) (Secondary Phone#) (Email Address)
Who referred you to ADVANCE@PFH?
(Referral Last Name) (Referral First Name) (Referral Relationship to Applicant)
Yes No
(Referral Phone#) (Referral Email Address)
If Female, are you Pregnant? Yes No Unknown
Have you ever used IV Drugs? Yes No; Last Date of IV Drug Use:
Are you having any thoughts of harming yourself or others at this time? Yes No
If you are at immediate risk; please call 911
Have you ever attempted suicide? Yes No If yes, Date of last attempt?
Have you ever received treatment fora Substance Use Disorder? Yes No
Outpatient? Yes No; How many times? Date of last treatment:
Residential? Yes No; How many times? Date of last treatment:
Have you ever received treatment for a Mental Health Disorder? Yes No
Outpatient? Yes No; How many times? Date of last treatment:
In a Hospital? Yes No; How many times? Date of last treatment:
Are you currently taking prescribed or over-the-counter medications? Yes No
If yes, please list:
Will you be able to bring 14-21 days of medications with you to treatment? Yes No
Please share whatyou expect to gain from treatment at ADVANCE@PFH:
Do you feel ready to make changes in your use of drugs and/or alcohol? Why or Why Not?
If you have been in Substance Use Treatment/Recovery previously; what worked for you?
Do you have any preferences/needs that would assist you in engaging fully in Recovery?
What obstacles do you foresee that might prevent you from enjoying a successful Recovery?
ADVANCE@PFH is a Tobacco Free treatment environment; Nicotine Replacement Therapies coupled with other Tobacco Cessation tools are readily available to assist program participants.
Do you use Tobacco Products? Yes No
If you currently use tobacco;are you willing to adhere to Tobacco Free Guidelines and participatein Tobacco Cessation programming? Yes No
Do you need assistance with transportation to and from treatment? Yes No
Who do you currently live with?
Do you have a significant Other? Yes No
Is he/she willing to support you in treatment participating in therapeutic sessions? Yes No
Willany of your family members be willing to support you and participate in therapeutic sessions?
Yes No
Income & Insurance
What is your monthly income?
How many people are you responsible for supporting with your income?
If determined eligible, will you be willing to apply for Medicaid? Yes No
If ineligible for Medicaid, will you be willing to apply for insurance through the Health Insurance Marketplace? Yes No
Is there anything else about yourself that would be important for us to know about you that you would like to share?
Certification of Information
I do hereby acknowledge that the information provided herein is true and accurate. I understand that I will be responsible for providing verification of Missouri Residency if approved for admission to ADVANCE@PFH. I understand that my financial situation will be reviewed at 90 day intervals. If my financial situation changes, I agree to notify Preferred Family Healthcare within 30 days.
I have read the Participant Handbook. I understand that ADVANCE@PFH is a Tobacco Free environment and that Nicotine Replacement Therapies and other tobacco cessation tools will be made available to me during my treatment stay; I am willing to be Tobacco Free during my treatment episode.
I recognize that I will undergo a full Assessment upon admission to PFH and if at that time it is determined that an alternate level of care is more appropriate; staff at ADVANCE@PFH will assist me in accessing applicable treatment services. If admitted to PFH I am willing to do my best in order to get the maximum benefit from treatment.
______
Applicant SignatureDate
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Guardian Signature (if applicable)Date
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