Intake Form

Our comprehensive 45 page intake form gives us a close look at your medical/social history and current health status.

Tell Us Your Story

The intake form is one of the most important aspects of the program. It usually takes between one to two hours to complete.

Please take your time telling your story and fill out the form to the best of your ability. The more we know, the better we can help you. If you are not sure how to answer, simply leave a question mark next to the question.

Please follow the instructions below carefully.


This form must be saved and filled out in Adobe or printed and filled out manually. DO NOT fill it out in your browser or you will lose your work.

Once completed, please send the filled out form to

Click the button below to download the form.