Saving Lives through Real Treatment and Real Results

Alcohol and Drug Treatment Program (30, 60, 90 days plus)

Call Now! WE CAN HELP! 1-888-687-7332

Now Accepting Most Insurances

Get Help Now!

1-888-687-7332

Online Application

Patient Testimonials

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Admission Application

A staff member will contact you within 24 hours after you have completed the pre-admission application to answer any questions and continue the process. Completing the pre-admission form is not a guarantee of or obligation for treatment. Your information is confidential and will only be seen by The River Source staff. Fields marked * are required.

Name of Person Filling Out This Form: *

I Am Looking For:

Relationship to Patient:

Email Address: *

Phone Number:

Alternate Phone Number:

Street Address:

City:

State:

Zip Code:

Patient Information
(If other than Self)

Patient Name:

Age:

Date of Birth:

Gender:

Form of Payment for Treatment:

Marital Status:

Number of Children:

Patient Street Address:

City:

State:

Zip Code:

Insurance Information

Name of Insurance Provider:

Name on the Insurance Card:

Name of Policy Holder:

Policy Holder's Date of Birth:

Group #:

Identification #:

Customer/Membership Service Toll Free Number:

Mental Health Status:

I'm Concerned About My:

	Yes	No
Alcohol Consumption
Prescription Drug Use
Use of Other Drugs
Are You a Danger to Yourself or Others?
Have you Attempted Suicide in the Last 12 Months?
Have you Considered Suicide in the Last 12 Months?

Are there legal agencies involved :

(ex. courts, attorneys, probation officers)

Do you have allergies :

(List all allergies ex. food or medications)

Do you have any history of seizures?:

Yes

No

Are you on any medications?:

(list all medications)

Types of alcohol and amount per day or week:

Types of drugs and amount per day or week:

Are you willing and able to get treatment at The River Source?:

Yes

No

Anticipated date of admission to River Source:

Anticipated length of stay:

Flight / Airline information:

(ex. airline, flight number, arrival date, arrival time etc.)

If we are picking you up at the airport please give us a physical description of yourself:

(height, weight, hair color, facial hair, eye color, what clothing you will be wearing that day etc.)

I am concerned about:

What are your goals with us? :

(ex. To live a life clean, sober and in recovery)

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Testimonials

"I was a broken individual before coming to The River Source. Drugs and Alcohol had taken total control over my life. I could not stand being sober, I was not comfortable in my own skin. I lost any job I ever had, failed college time and time again, lost all respect from my family, and I had no self worth. Coming to The River Source and getting clean was the best decision I ever made. They taught me how to be myself and showed me how to live a good life drug free. They showed me a strong..."

Justin M. - May 2012

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Tour Our Facility

Meet Our Staff

Liz Martin Vice President of Operations

Liz Martin

Vice President of Operations

Dr. Walmer Medical Director

Dr. Walmer

Medical Director

Jenny Cilwa - Clinical Director Casa Grande

Jenny Cilwa

Clinical Director - Casa Grande

Dr. Dave Arneson Naturopathic Medical Doctor

Dr. Dave Arneson

Naturopathic Medical Doctor

Dr. LaCoss N.M.D.

Dr. LaCoss

N.M.D.

Dr. Fred Arnold Natturopathic Medical Doctor

Dr. Fred Arnold

Naturopathic Medical Doctor