Pre-Screen Application Form

We’ve designed this form to help you get started as quick and easy as possible. This is the first step of a rewarding journey.

Filling out the application below will help provide us with all the information we need to start assessing your needs and what program is best for you. In addition, please click the button to download our Release of Information form and return to us.

If you run into any issues while filling out, please feel free to Contact Us for further help.

Download Release of Information Form

Prescreen Form

First Name

Last Name

Date of Birth

Phone/Mobile

Email

Address Line 1

Address Line 2

City

State

Zip Code

Which county do you live in?

What are your current living arrangements?

Do you have insurance?

Yes

No

Which insurance do you use?

Recent Drug Usage (click the plus icon to the right to add more)

Drug	Route	Amount	Frequency	Date Last Used

Do you have pending legal charges?

Yes

No

Warrants or Court Dates

Are you on Probation or Parole?

Yes

No

P.O. Name

Medical Treatment History (click the plus icon to the right to add more)

Medications & Diagnosis	Treatment Provider

Mental Health Treatment History (click the plus icon to the right to add more)

Medications & Diagnosis	Treatment Provider

Alcohol and Drug Treatment History (click the plus icon to the right to add more)

Treatment Center	Dates	In/Outpatient	Length of Treatment	Length of Sobriety

I understand that this information will be submitted to a staff member at Samaritan Recovery Community, and that my information will remain private and not shared with anyone for any reason other than to help determine treatment through SAMCTR

I understand

Need more information?

If you have any further questions that haven't been answered, we'd love to hear from you and help in any way we can. Click the button to see the many ways of getting in touch.

Contact Us