Date:

Name:

Address:

City/State:

Telephone:

Birthdate: Age:

Marital Status: Single Married Divorced Separated

In Case of an Emergency Notify:

Relationship:

Telephone:

Drug of Choice: Drugs Alcohol

Type:

Date of Last Use:

Any Length of Time Substance Free: Yes No

How Long? When?

Previous Treatment Yes No

Where? When?

AA /NA Experience:

When? How Long?

Current Prescribed Medications:
1)
2)
3)

The Fern House Residence has zero tolerance for any alcohol and drug use. The Fern House also prohibits the use of any narcotic or non-narcotic prescribed medication that may be mood or mind altering.


I understand and agree that upon admittance to the Fern House Residential Program I must pay a one-time administration fee of $50.00 and 1 week rent ($203.00). Total due upon admittance $253.00.