Verify Your
Insurance
Call Today!
866-294-9331
Menu
About Us
Our Approach
Our Team
Our Guarantee
Our Facilities
Treatment Programs
Our “Reclaim Your Life” Program
Drug & Alcohol Detox Program
Men’s Inpatient Treatment Program
Women’s Inpatient Treatment Program
Outpatient Treatment Programs
Lifetime Alumni Program
Recovery Services
Telehealth IOP
Naturopathic Therapies
Individual Counseling
Group Therapy
Family Education
12-Step Principles
Co-Occurring Disorders
Special Tracks
Substance Abuse
Alcohol
Cocaine
Methamphetamine
Heroin
Opioids
Benzodiazepines
Psychedelics
Marijuana
Prescription Drugs
Methadone
Admissions
Getting Started
Insurance
Resources
Addiction Blog
FAQs
Testimonial
Careers
Professional Insights
Contact Us
Arizona City
Gilbert
Phoenix
Tucson
West Valley
Product
was added to your cart
Cart
Verify Your Insurance
Apply Online
General Information
How did you hear about us?
*
Name of Person Filling out this form
*
Relationship to Patient
*
Phone Number
*
Alternate Phone Number
*
Email
*
What State Are You Located In?
*
Patient Information
Patient Legal Name
*
D.O.B.
*
Address
Street Address
City
State / Province / Region
ZIP / Postal Code
Gender
Male
Female
Form of Payment
Emergency Contact Name
Emergency Contact Phone Number
Do you give us permission to contact this person in an emergency?
Yes
No
Admission Assessment
Are you a danger to yourself or others?
Yes
No
Have you had any past suicide attempts?
Yes
No
In the last 12 months, were there thoughts of suicide, with an intention/plan?
Yes
No
Currently, are there any thoughts of suicide along with an intention and plan?
Yes
No
Have you ever been hospitalized for a mental health condition?
Yes
No
List any medication(s) or food you are allergic to below (Leave blank if none)
Have you ever had a seizure?
Yes
No
List all current medications, dosage, and the reason they are prescribed?
Are you currently taking antipsychotic or other psychiatric medication?
Yes
No
Are you taking the medications as prescribed?
Yes
No
Do you have any diagnosed medical conditions?
Yes
No
Please list any immediate medical concerns
In the past 6 months, any rashes, wounds, lung diseases, or other infections?
Yes
No
Have you attended any drug and alcohol treatment centers in the past?
Yes
No
Do you drink alcohol?
Yes
No
Have you abused prescription medications or used street drugs in the past 12 months?
Yes
No
Date you last used drugs or drank alcohol?
Yes
No
In the past 12 months, have you been arrested?
Yes
No
Briefly describe your relationship with your immediate family:
In the past 12 months, have you held steady employment?
Yes
No
Please choose which option best describes your network of friends:
Please describe your willingness to be helped
Anticipated date of admission to The River Source
Anticipated length of stay at The River Source:
Did you find the program through one of our treatment Paths?
Yes
No
Do you have interest in participating in one of our paths?
Yes
No
Application for Admission The River Source reserves the right to disqualify applicants for specific medical reasons that require a higher level of care. These medical reasons include, but are not limited to: Active Tuberculosis Suicidal Ideation with a Plan, Means, and/or Intent Acute Psychosis Infectious Disease A person who moves to a higher level of care will again become eligible for one of the programs offered at The River Source once their medical situation is successfully handled.
I have read and fully understand all of the above.
*
I have read and fully understand all of the above.
Menu
Online Application
First Name
*
Last Name
*
Applying For
*
*Applying For:
Myself
Loved One
D.O.B.
*
Phone
*
Email
*
Insurance Name
Member ID
Message
Hidden
Form Title
Hidden
Page URL
×
Insurance Verification
Full Name
*
*D.O.B.
*
Phone
*
Email
*
Insurance Name
*
Member ID (optional)
Message
Hidden
Form Title
Hidden
Page URL
×
Insurance Verification
Full Name
*
*D.O.B.
*
Phone
*
Email
*
Insurance Name
*
Member ID (optional)
Message
Hidden
Form Title
Hidden
Page URL
×
Full Name
*
Phone Number
*
Email Address
*
How Can We Help?
*
Hidden
Form Title
Hidden
Page URL
CLOSE
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
×
Your Name
*
Your Phone Number
*
I Am Applying For:
*
Myself
Loved One
If Applying for a Loved One, What is Your Loved One’s Name?
Have You Spoken to a Member of Our Admissions Team Yet?
*
Yes
No
CLOSE
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Hidden
Form Title
Hidden
Page URL
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Hidden
Form Title
Hidden
Page URL
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Hidden
Form Title
Hidden
Page URL
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Hidden
Form Title
Hidden
Page URL
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
×
Full Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Hidden
Form Title
Hidden
Page URL
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Hidden
Form Title
Hidden
Page URL
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Hidden
Form Title
Hidden
Page URL
×
Online Application
First Name
*
Last Name
*
Applying For:
*
Applying For:
Myself
Loved One
D.O.B
*
DD slash MM slash YYYY
Phone Number
*
Email Address
*
Insurance Name (if applicable)
Hidden
Form Title
Hidden
Page URL
×
×
Your Name
*
Your Phone Number
*
I Am Applying For:
*
Myself
Loved One
If Applying for a Loved One, What is Your Loved One’s Name?
Have You Spoken to a Member of Our Admissions Team Yet?
*
Yes
No
×
