Application For Admission

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V - BACKGROUND INFORMATION
1. Please describe pregnancy, birth and early childhood development of applicant.
2. Has the applicant experienced any significant loss or emotional trauma? If yes, please describe, including particular age(s).
3. Describe any physical trauma (ie: concussions, accidents, injuries) include age and frequency.
4. Describe any surgeries, include age and the result.
5. Describe any allergies applicant has.
6. Describe any current or history of self-harm behaviours.
7. Describe any anxiety applicant may suffer from.
8. Describe any depression applicant may suffer from.
9. Describe any significant anger or violence issues in the past 12-months.

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VI - ALLERGIES, MEDICATIONS, SUPPLEMENTS
10. List any known allergies of applicant (include food allergies, if any) and how severe.
11. List any medications / prescriptions, and reason (diagnosis).
12. List any supplements the applicant takes regularly.

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VII - SUBSTANCE ABUSE (ADDICTIONS)
13. Describe any known history of substance abuse (list substance, age when started, current usage / frequency).
14. Describe any other addiction(s) (gaming, texting, online, gambling, sex, eating, shopping, etc.)

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VIII - OTHER COMMENTS
15. What would be the ideal day / date for admission?
16. Explain any other important issues(s) or concern(s).?
17. Describe your desired goal or outcome for seeking help.
18. Please describe how you learned of, or discovered Emergo Recovery's program (if online, please describe how / where). (Optional)
19. What did you like best about Emergo Recovery's website? (Optional)

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