If you or a loved one needs treatment, our pre-screening questionnaire is the quickest way to start the process. This questionnaire asks a range of questions including detailed histories of mental health, substance use, and medical procedures. We collect medical, mental health and substance use histories to be able to form the best possible treatment plan. If you or the individual you are filling out this form for has insurance, this information will also help us make sure that insurance is able to cover as much of the costs of treatment as possible. If you are filling out this questionnaire for someone other than yourself, we ask you to be as thorough and accurate as possible. Please use the information of the individual who will be attending treatment. Any information submitted is transmitted through a secure connection and stored on HIPAA compliant servers. We take your privacy very seriously and are committed to making sure any personal information is entirely protected.
To apply for services, click on the button below to access our online prescreen application. You can also download a PDF version of this form here. Our fax number is: (262)-753-6897.