INSCAPE APPLICATION

PERSONAL INFORMATION

Name

First Name

Last Name

Date of Birthday

YYYY

ADDRESS INFORMATION

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

CONTACT INFORMATION

Phone Number

Country

(###)

###

####

EMERGENCY CONTACT

Name

First Name

Last Name

Phone

Country

(###)

###

####

TREATMENT INFORMATION

Primary Issues for Treatment

Please describe the specific substance use disorder, addiction, or related concerns for which you are seeking treatment

Type of Treatment Sought

Previous Treatment History

Preferred Treatment Start Date

YYYY

Treatment Goals & Motivation

What motivates you to seek treatments? What are your treatment goals?

HEALTH INFORMATION

Mental Health History

Have you ever been diagnosed with a mental health disorder? If yes, please specify the diagnosis and date. Have you experienced thoughts of suicide in the past six months?

Physical Health & Medical History

Do you have any physical health issues, including illness, severe allergies, physical limitations, pain, or injuries? If yes, please specify. Have you ever been hospitalized for illness, injury, or other reasons? If yes, please provide details and dates. Are there any hereditary or family illnesses that we should be aware of? If yes, please specify.

Recent Violent Incidents

Have you been involved in any violent incidents within the past three months? If yes, please provide details.

SUBSTANCE USE & LEGAL INFORMATION

Recent Substance Use (Last 3 Months)

Please list all substances you have used in the past three months, including street drugs, alcohol, and all prescription medications (both psychoactive and non-psychoactive), along with the frequency of use.

Current Legal Proceedings

Are you currently involved in any legal process? If yes, please explain as much as possible.

ADDITIONAL INFORMATION

How did you hear about us? *

How did you hear about us?

Additional infomation

Please share any additional information you think would be helpful for us to know.