Intake Application

Starfish Recovery & Wellness

Please provide as much information as you can and a member of our team will be in touch.

Starfish Application

First Name

Last Name

Application Date

Phone #

Gender

Date of Birth

Referred by (if any)

Insurance Carrier (if any)

Substance of Choice

Date of Last Use

Mental Health Diagnosis (if any)

Current/Previous Clinical Care?

Yes

Enter Name of Hospital, Clinician, or Practice

Level of Care

Detox

PHP

IOP

Individual Counseling

Current and Past Medications, including dosages

Criminal History, including any requirements to enter or complete a recovery program or recovery housing