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 and Past Medications, including dosages

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