Verify Your
Insurance
Call Today!
866-294-9331
Menu
About Us
Our Approach
Our Guarantee
Our Team
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
Product
was added to your cart
Cart
Verify Your Insurance
Apply Online
Rehab Programs: Admin Application
Youth Admission Form
How Did You Hear About Us?:
*
-Select-
Google
Bing
Yahoo
Rehabs.com
SoberRecovery.com
ArizonaDrugRehab.net
ColoradoDrugRehab.net
DrugRehabCA.net
DrugRehabilitationFlorida.com
DrugRehab.info
GADrugRehab.com
IdahoDrugRehab.net
IllinoisDrugRehab.net
MontanaDrugRehab.net
NewMexicoDrugRehab.net
NJDrugRehab.org
NorthCarolinaDrugRehab.net
NYDrugRehab.com
TexasDrugRehab.net
UtahDrugRehab.net
WashingtonDrugRehab.org
WyomingDrugRehab.net
Friend
Alumni
Other
If Other, please explain:
*
Please let us know how you found theriversource.org (friend or keywords)
Name of Person Filling Out This Form:
*
Relationship to Patient:
*
Email Address:
*
Phone Number:
*
Alternate Phone Number:
What state are you located in?:
*
-Select-
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Marshall Islands
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Marianas Islands
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Patient Information
Male Patient's Legal Name:
*
Male Patient's Phone Number:
*
Age:
*
-Select-
13
14
15
16
17
Date of Birth:
*
Date Format: MM slash DD slash YYYY
Responsible Party Information
Parent/Guardian Name:
*
Relationship:
*
Custody of Patient?:
*
Yes
No
Home Number:
*
Address:
*
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer:
*
Work Number:
*
Other Parent or Guardian
Parent/Guardian Name:
Relationship:
Custody of Patient?:
Yes
No
Home Number:
Address:
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Employer:
Work Number:
Form of Payment:
*
-Select-
Self-Pay
Insurance
Address
Street Address
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Is the patient a danger to their self or others?:
*
Yes
No
If yes, please explain:
*
Has the patient had any past suicide attempts?:
*
Yes
No
If yes, when was his most recent attempt? What method was used?:
*
In the last 12 months, has the patient had any thoughts of suicide, along with an intention and plan?:
*
Yes
No
If yes, when was his last suicidal thought, along with an intention and plan?:
*
Currently, does the patient have any thoughts of suicide along with an intention and plan?:
*
Yes
No
If yes, please explain:
*
Has the patient ever been hospitalized for a mental health condition?:
*
Yes
No
If yes, please explain:
*
Please list all medication and food allergies:
*
Has the patient ever had a seizure?:
*
Yes
No
If yes, when and what caused it?:
*
Please list all current medications, dosage, and the reason they are prescribed:
*
Is the patient currently taking antipsychotic or other psychiatric medication?:
*
Yes
No
Does the patient currently have a 30 day supply of his antipsychotic or other psychiatric medication or does he have valid refills?:
*
Yes
No
If the patient does not have a 30 day supply of his antipsychotic or other psychiatric medication he may be required to see a psychiatrist or his physician who can prescribe the patient his medication. The patient's cost for this service is $100-$300 depending on his psychiatric service need.
Is the patient taking the medications as prescribed?:
*
Yes
No
Please list any immediate medical concerns:
*
In the past six months, has the patient had any rashes, wounds, abscesses, respiratory diseases, or other infections?:
*
Yes
No
If yes, please describe the situation and the treatment that the patient received:
*
Has the patient attended any drug and alcohol treatment centers in the past?:
*
Yes
No
If yes, when was the date of his previous treatment?:
Date Format: MM slash DD slash YYYY
Does the patient drink alcohol?:
*
Yes
No
Please specify how often the patient drinks alcohol:
*
Daily
Weekly
Monthly
Yearly
Binge Drink
How much does the patient drink?:
*
1-2
3-4
5 or more
What type of alcohol?:
*
Beer
Wine
Liquor
Has the patient abused prescription medications or used street drugs in the past 12 months?:
*
Yes
No
If yes, please list all substances used as well as how frequently the patient uses them:
*
Date the patient last used drugs or drank alcohol?:
*
Date Format: MM slash DD slash YYYY
In the past 12 months, has the patient been arrested?:
*
Yes
No
If yes, why?:
*
Briefly describe the patient’s relationship with their immediate family:
*
Is the patient currently enrolled in school?:
*
Yes
No
If not, why?:
*
Please specify the patient's last grade completed in school:
*
Does the patient have a:
*
-Select-
Supportive Network
Substance Based Friends
No Friends
Please describe the patient’s willingness to be helped:
*
Anticipated date of admission to The River Source:
*
Date Format: MM slash DD slash YYYY
Anticipated length of stay:
*
-Select-
5 Day Detox
10 Day Detox
30 Days
60 Days
90 Days
Outpatient
Full Continuum of Care
More
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 River Source program once medical situation is successfully handled.
*
I have read and understood the above.
Menu
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
Form Title
Page URL
CLOSE
Full Name
*
Phone Number
*
Email Address
*
How Can We Help?
*
Form Title
Page URL
CAPTCHA
CLOSE
CLOSE
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Full Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Name
Phone
*
Email
*
Select Date & Time
*
How Can We Help?
Form Title
Page URL
CAPTCHA
×
Online Application
First Name
*
Last Name
*
Applying For:
*
Applying For:
Myself
Loved One
D.O.B
*
Date Format: DD slash MM slash YYYY
Phone Number
*
Email Address
*
Insurance Name (if applicable)
Form Title
Page URL
CAPTCHA
×
Verify Your Insurance
Full Name
*
D.O.B
*
Date Format: DD slash MM slash YYYY
Phone
*
Email
*
Insurance Name
*
Member ID (optional)
Form Title
Page URL
CAPTCHA
×
×
