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Please visit www.farrell-tc.com/programs/intensive-residential-treatment/ for more information about different levels of care.
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What is the substance use problem(s)?
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History of use in the past 30 days?
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Any recent substance use inpatient/residential admissions? When/Where?
History of overdose/administered naxolene/narcan in the past 30 days?
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Please list medications being taken currently (including MAT):
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If prescribed Methadone, from which OTP? (for coordination of care)
Are any of the following applicable? Please select all that apply
Difficulty walking
Difficulty with stairs
Use medical devices
If yes, please specify (e.g., CPAP, Nebulizer, Oxygen Tank, Walker/Wheelchair, Insulin Pump, continuous glucose monitor (CGM):
Please list psychiatric diagnoses or concerns:
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Any recent psychiatric hospitalizations (when/where):
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Have you noticed any changes in memory, thinking, or ability to focus that are affecting daily life? Please specify:
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Plan after completing program (e.g., home, friend’s house, shelter, sober living, longer term care):
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To submit this form, please attach proof of a negative PPD test (within the last 6 months), most recent physical, and documentation of mental health diagnosis:
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About
Our Staff
Facilities
Careers
Admissions
What to Bring
Programs
Intensive Residential Treatment
Intensive Outpatient Treatment
Individual & Group Outpatient Therapy
Aftercare
Resources
News & Updates
For Clients
For Families
For Providers
Donate
Contact
