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ADMISSIONS SCREENING

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Our confidential screening consists of questions about your substance use history, mental health, and personal circumstances. This information enables us to develop a personalized treatment plan tailored to your specific situation.​

 

After completing the screening, our admissions team will review your application promptly and reach out to discuss the next steps.​

 

Taking this initial step can be pivotal in your path to recovery. Our experienced and compassionate staff are here to guide you through the process, ensuring you receive the support and care you need.​ If you have any questions or require assistance while completing the assessment or application, please don't hesitate to contact us. We are committed to helping you achieve a healthier, substance-free life.

QLC Screening

IMPORTANT INFORMATION

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PAYMENT TYPES ACCEPTED

  • Cash

  • Check

  • Credit Card

  • Insurance

  • State Funding

  • ACC

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THE FOLLOWING ITEMS ARE REQUIRED DURING CHECK-IN:

  • Picture ID

  • Driver's License

  • State ID

  • Social Security Card

  • Proof of Income

  • Pay Stubs

  • Tax Return

  • Insurance Cards

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If you are being treated for any medical or mental health issues at this time, please bring statement from doctor with any restrictions and/or allergies you may have. You will also need to bring 30 days of current medication in prescription bottles.

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IF YOU HAVE FAILED TO BE HONEST ON YOUR MEDICAL/MENTAL HEALTH INFORMATION, YOU MAY NOT BE ABLE TO ENTER TREATMENT ON ARRIVAL

 

ADDITIONAL ITEMS YOU ARE REQUIRED TO BRING: 

  • 7 Days of Clothing

  • Personal Hygiene Products (Sanitary, Shampoo, Toothbrush, Toothpaste)

  • Washing Powder and Money for Washer/Dryer

  • 2 Bath Towels, 2 Face Towels

  • Shoes (1 Dress, 1 Casual)​

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THE FOLLOWING IS RESTRICTED FROM CHECK-IN:

  • Any Electronic Products

  • Cell Phones

  • Reading Materials (Except AA/NA/CA)

  • Weapons

  • Food

  • Inappropriate Clothing

Date of Birth
Month
Day
Year
Referral Source
Self
Court
Detox
Probation Officer
Any Withdrawal Symptoms?
NO
YES
Previous Treatment?
NO
YES
Are You Pregnant?
NO
YES
Are You Under Doctor's Care?
YES
NO
Seizures?
NO
YES
Hypertension?
NO
YES
Recent Attempts of Self Harm or Suicide?
NO
YES
Are You Currently in the Hospital?
NO
YES
Do You Have Any Medical Problems That Will Interfere with Treatments for the Next Thirty (30) Days?
NO
YES
Are You Disabled and Unable to Work?
NO
YES
Do You Have Any Allergies?
NO
YES
Are You on a Special Diet?
NO
YES
FAMILY HISTORY: Status
Married
Single
Separated
Divorced
Widowed
Children?
YES
NO
Does Child(ren) Live with You?
YES
NO
Do You Have Parental Rights?
YES
NO
Have You Served in the Miltary?
NO
YES
LEGAL INFORMATION: Have You Recently Been Incarcerated?
YES
NO
Are You a Sexual Offender?
NO
YES
Any Pending Charges?
YES
NO
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