CURA, INC.

ADMISSIONS APPLICATION

CURA Inc. is a Non-Profit Organization that provides Substance Abuse and Behavioral Health Services in an Outpatient, Short Term or Long Term Capacity. By completing the form below you are expressing an interest in being considered for admission into any one of these programs.  CURA, Inc. complies with all Federal and State mandates with regards to confidentiality and privacy laws. Please allow three business days for the Intake department to review and respond to your application.

Application (563)

Contact Information

1. Date(required)
2. Full Name (required)
3. Address (required)
4. City (required)
5. State(required)
6. Zip Code(required)
7. Date of birth(required)
8. Phone(required)

Status Information

1. What services are your seeking: Scroll Down for Services Intensive Outpatient Short Term Long Term Outpatient Other
2. What language would you prefer these services be provided in?
3. English Spanish Other
4. Are you homeless:
5. Yes No
6. Who is your healthcare provider:
7. None
8. Carrier:
9. Policy#
10. Are you currently or have you ever been treated for: High blood pressure Stroke Heart disease Diabetes Stomach disorders Kidney disease sleep disorders other

DRUG/ALCOHOL/TABACOO USE

1. Drug(s) of choice
2. Last time taken:
3. Do you smoke:
4. Yes No

LEGAL STATUS

1. Are you under the supervision of a probation/parole officer at this time?
2. Yes No

REFERRAL SOURCE

1. How did you find out about CURA’s program services? Community Organization Courts State Program Family/Friends

 

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