Request for Services

    REQUEST FOR SERVICES

    Applicant Information

    90 Days Treatment
    6 Months Treatment
    In-House Treatment (Intensive Outpatient)
    Off-Site (Outpatient)
    Telehealth
    First Name:
    Last Name:
    DOB:
    SSN:
    Email:
    Phone (Home):
    Phone (Cell):
    Phone (Other):
    Current Address:
    City:
    State:
    Zip Code:
    Gender
    MaleFemaleOther Specify:


    Veteran of the U.S. Military Services?
    YesNo
    Do you have a stable Internet connection?
    YesNo

    Referring Agency

    New Intake
    Re-admission
    Voluntary
    Court Ordered
    Are you being referred by an Agency? (Probation/Parole, Court Compliance, CYFD, etc.)YesNo

    Please provide agency contact information:
    Agency:
    Contact Name:
    Phone:
    Email:

    Emergency Contact

    First Name:
    Last Name:
    Address:
    Phone:
    City:
    State:
    Zip Code:
    Relationship:

    Reason For Seeking Treatment

    Drug(s) of choice:
    Date of Last Use:

    Medical Insurance

    Insurance Company
    Address:
    Phone:
    City:
    State:
    Zip Code:
    Insurance Id#:
    Group Id#:

    Criminal Offense History

    Are you required to register as a sex offender?

    YesNo


    Have you been convicted of a felony?

    YesNo

    Have you been convicted of a misdemeanor?

    YesNo

    Do you currently have any pending charges?

    YesNo

    Have you or are you currently affiliated with any gang related activity?

    YesNo

    Advanced Directives: (Check all that apply)

    ALL PAPERWORK REFERRING TO ADVANCED DIRECTIVIES MUST BE PROVIDED BEFORE APPLICATION WILL BE CONSIDERED

    ACKNOWLEDGMENT OF APPROVED AND PROHIBITED ITEMS

    It is the policy of FWBH that any prohibited items are not allowed on property at any time without written approval by the Executive Director. Prior to admission, a thorough search of your person and property will be conducted. Possession of any of the prohibited items may result in revocation of your application and intake status or offer. Possession of any prohibited items after the intake process is completed may result in your immediate discharge from the facility.
    Approved Items Allowed Upon Intake
    • Pants/Jeans (up to 10)
    • Sweat Pants (up to 10)
    • Sweat Shirts (up to 10)
    • Shirts (up to 10)
    • Shoes (up to 3)
    • Underwear (up to 10)
    • Bras (up to 10)
    • Pajamas (up to 3)
    • Jackets/Light sweater (up to 3)
    • Shower Shoes (1)
    • Slippers (1)
    • Robe (1)
    • Belts (1)
    • Hats (2)
    • Towels (5)
    • Washcloths (5)
    • Undershirts (7)
    • Musical Instruments Ex: Drums
    (1-2)
    • Art Supplies
    • 30 day supply of all current
    medication and medical supplies
    Starter Kit (Must be brought within 36 Hours of Admission)

    *Once starter kit is exhausted, you will need to purchase additional items from the FWBH onsite store*

    • Basic Hygiene Items-Shampoo, Conditioner,
    Soap, Guarded Razors, Shaving Cream, and
    Feminine hygiene products
    • Laundry Detergent
    • One carton of cigarettes
    Non-Approved Items
    • Outside Food or Drinks
    • Nail Polish/Polish Remover
    • Hairspray (alcohol must be at least the 4th ingredient
    listed)
    • Perfume (alcohol must be at least the 4th ingredient
    listed)
    • Coconut Oil
    • Straight Razors
    • Sharpie Markers
    • Bandanas
    • DVD Players/Portable DVD Players
    • Gaming Console, Fire Stick, Roku, Google TV
    or any media streaming devices
    • Sexually oriented materials and/or products
    • Essential Oils
    • Power Strips/3 way connectors
    • Guns/Ammunition/Knives
    • Pepper Spray
    • Stun gun/Tasers
    • Multi-use tools (Leatherman)
    • Any item fashioned as a weapon

    Medical History

    Can you walk up and down stairs?

    YesNo

    Are you diabetic? Do you require a special diet?

    YesNo

    Do you currently have any major medical conditions?

    YesNo

    Are you currently taking any medications?

    YesNo

    Do you have any medication allergies and adverse reactions:

    YesNo

    Do you have any current psychiatric and/or medical medications

    YesNo

    What is the highest level of education you have completed?




    Were you ever diagnosed with a learning disability?

    YesNo

    Have you ever worked with a mental health provider?

    YesNo

    Do you require an Oxygen tank?

    YesNo

    Current Height:

    Current Weight:

    Last visit to primary care physician:

    Have you ever been hospitalized?

    YesNo

    Have you or are you being treated for any of the following or are you currently having symptoms related to any of the following?

    Please explain for each box you checked


    PSYCHIATRIC HISTORY

    Personal psychiatric history (Check all that apply):

    Please explain each box you checked above


    WAIVER TO RELEASE APPLICATION STATUS

    I hereby authorize Four Winds Behavioral Health to release information regarding my application status. This authorization
    of release includes my application approval, estimated wait time, program acceptance, and intake for the purpose of aiding, collaboration and coordination of services.
    I authorize the following people to obtain my application status:
    Name:
    Relationship:
    Name:
    Relationship:
    Name:
    Relationship:
    Name:
    Relationship:

    Telehealth Terms of Treatment

    To comply with current safety restrictions related to COVID 19, Four Winds Behavioral Health (FWBH) utilizes a combination of telehealth and in-person services to provide Addiction and Mental Health Treatment.
    FWBH is taking the necessary steps to create a safe, supportive experience that complies with HIPPA privacy laws.
    Please read the following:
    • Must have use of a video/audio capable device that is charged or plugged in (Smartphone, tablet, or computer)
    • Must have internet access with a stable Wi-Fi connection
    • Must be in a well-lit, quiet, and private location (HIPPA requirement)
    • Should be logged into the session 5 minutes before the session start time
    • Must be on time to be considered present for the session
    • Telehealth is an audio and video communication which requires discretion with appearance, location, and dress.

    REQUIRED: CHOOSE AN OPTION

    Yes, I understand and I am able to engage in services via telehealth.

    Or

    Yes, I understand but I am NOT able to engage in services via telehealth. I also understand this may delay my ability to receive services. I will contact FWBH immediately if this changes.

    Contact scheduling at 505-313-7055 immediately regarding changes to your contact information (Phone number or email address). Always leave BOTH, a message AND email [email protected] with any changes.

    Redisclosure: I understand that Four Winds Behavioral Health cannot guarantee that the recipient will not disclose my application status to a third party.
    I understand that I can revoke my waiver at any time and for any reason. I understand that my Authorization will automatically expire one year from the date of my signature unless I request it be revoked earlier (see below).

    By signing below, I certify all information is true and correct to the best of my ability and grant permission for
    Four Winds Behavioral Health to contact Probation/Parole/Court Officer if necessary.
    In case of an emergency, FWBH has my authorization to notify my Emergency Contact.
    "By submitting this application, I acknowledge that a staff member of this facility may be calling to ask follow up questions or communicate my application status. I authorize any staff member of the facility to call and identify themselves as calling from the facility to speak to me."

    Signature:

    Please only click submit one time.