The Walker House
Home
Services
Admisssions
Our Program
About Us
Contact
Community
Walk with A Purpose
A New Life Begins With The First Step
Call Now
Growth through Unity.
Name *
Phone Number *
Email *
SSN *
Date of Birth *
Gender *
Insurance Provider *
Did you come from another facility? If so where?
Have you been to the Walker House before? If so, what happened and why did you leave? *
Mental Health Diagnosis
Schizophrenia
Schizoaffective
Borderline Personality
Bipolar
PTSD
Anxiety
Depression
Any Treatments?
Suboxone Taper
ART
EMDR
Implants?
Pacemaker
Cochlear Implant
Neuro-Stimulator
Pain Pump
Drains
Have you had any seizures in the last 6 months? If yes do you have meds? *
Do you have any open wounds? *
IOP or Self Pay bed? *
Do you have any relationships with current clients or staff? *
What Meds do you take? Must have 30 day supply (no benzos, opiates, amphetamines, other controlled) *
Any recent major medical problems? *
Do you have any specialist doctors? (cardiologist/neurologist) *
Infectious Diseases?
HIV
AIDS
HEP C
HEP B
HEP A
TB
Syphillis
NONE
Drug of Choice? Date of last use? *
Any other physical impairment that would stop you from basic daily activities or walking? *
Are You Currently Pregnant or Planning to be *
Yes
No
Leave this field empty
Submit form
Best Notes Form
