APPLICATION | The Mountain West Co

1.) Contact Information for the Person filling out this application

Please enter the first name of the person filling out this application

Please enter the last name of the person filling out this application

Please enter the email of the person filling out this application

Please enter a good contact number for the person filling out this application

2.) Information About the Patient

Patient's first name

Patient's last name

Patient's date of birth

Patient's mobile phone number

Patient's work phone number

Patient's home phone number

Patient's SSN

Patient's email

Patient is Homeless

Patient street address

Patient city

Patient ZIP

3.) Insurance Information

Member Insurance ID

Policy holder's first name

Policy holder's last name

Poliy holder's address

Policy holder city

Policy holder ZIP

Policy holder DOB

Policy holder's SSN

4) Additional Questions

What led you to contact Mountain West?

Please describe the withdrawal symptoms

Please explain your history of DTs

Please explain your history of seizures

Please explain your history of blackouts

5) Medical & Mental Health

Please explain your chronic health conditions

Please explain your mental health diagnoses

Please list medications and dosages

Explain recent hospitalizations (Where, What for):

Explain where you were and when:

6) Legal & Additional Information

Please list the county and PO:

Please list the social work agencies you are working with:

By checking this box, I am stating that all information provided has been truthful, and if it is found that I was not truthful with the information provided on this form it could be grounds or immediate discharge from the program.

By submitting this form, I acknowledge that my personal information will be processed in accordance with the Privacy Policy.View Privacy Policy

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MOUNTAIN WEST APPLICATION

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