Eudaimonia Sober Living and Extended Care

IOP Program Application


Demographics

Full Name:   

Date of Birth:   

Social Security Number:   

Address:   

Contact Number:   

Email Address:   

Desired admission date:

Emergency Contact

This contact will be used, in case of an emergency during your program stay.

Full Name:  

Relationship:  

Phone Number:  

Confidential Screening

This section will be used to expedite the admissions process. This information is protected by HIPPA and will be stored in our electronic medical record system.

Applying Individual

Person Applying:  

Relation to client:  

Best Contact Number:  

Client Information

Marital Status:  

Children:   

What are the current events, leading you to participate in an IOP program?:    

Medical History

Current or Previous Illness(es):  

Injuries or Surgeries (within the last year):   

Any seizures within the last year:   

Medication Information

Current Medications and Amounts:   

Current and Prior Treatment History

Program Name, Year and length of stay:  

Substance Use History

Substances used, frequency of use, approximate age of first use and the date of last use:   

Financials

Are you seeking to: 

 

If you are seeking for a verification of out of network benefits, please provide the information below:

Insurance Company:  

Phone Number:   

Member ID:   

Group Number:   

Type of Plan:   

By signing below, you understand that completion of this form, is not a guaranteed admissions into the program. By providing your insurance information above, you here by authorize Nova Recovery Center, d.b.a Eudaimonia Extended Care to verify and provide you the information regarding your available out of network benefits. You also understand this information will be stored in our electronic medical record system, for this inquiry and any future inquires you may have in our family of programs. The signing of this document, conveys your acceptance of the delivery of information through electronic signature.

Date: 

Leave this empty:

Eudaimonia Sober Living and Extended Care http://www.eudaimoniahomes.com
Signature Certificate
Document name: IOP Program Application
Unique Document ID: 0e368f0a701866d496b17d8e0353aa95d5b3ddba
Timestamp Audit
2016-08-03 11:17:10 CDTIOP Program Application Uploaded by Mathew Gorman - mat@novarecoverycenter.com IP 70.195.198.78