Teen drug and alcohol treatment - teen drug rehab - Washington, Oregon, Idaho, Montana

(We will contact you by phone or email within one working day of receiving your application.)

Child's Name:

Age:

Gender:

Parent/Guardian Name:

Phone Number:

Email Address:

Describe why the child needs inpatient treatment:

Has the child been assessed or seen at an outpatient facility?

Yes No

Name of agency or counselor:

Phone Number:

Is the child on probation or parole?

Yes No

Name of Probation Officer:

Phone Number:

Describe legal history:

Has this child been treated for or are you concerned about mental health problems? Yes No

Name of primary mental health provider:

Phone Number:

Please check concerns or symptoms:
Suicidal thoughts or actions Depression Violent behavior Thinking problems

Describe your concerns regarding child's mental and physical health:

Name and type of medical insurance:

Inpatient Information
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Inpatient Admissions Form
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