Apply to Stages

of Recovery

Do you or a loved one need treatment for addiction and/or dual diagnosis?

Our pre-admission questionnaire is the quickest way to get started. In this screening, we ask you to share details about the applicant’s history of mental health, substance use, and medical procedures. We also ask about any legal issues. Don’t worry, the application is confidential, secure, and stored on HIPAA-compliant servers.

Answering Our Questions Accurately Will Help Us Help You

To best address the applicant’s treatment, we request a comprehensive history of substance use and medical treatments related to mental health and substance use disorders. Please share as much information as possible. It helps us personalize our approach to the applicant’s treatment.

By providing information on current or prior legal issues, our case managers will be able to facilitate any necessary extraneous circumstances, including probation and parole.

Save Time and Money by Verifying Insurance While You Apply

By verifying insurance now, we can take the steps to ensure your insurance covers as much of the applicant’s treatment as possible. No insurance? No problem. We accept private payment, too.

Filling Out the Application for Someone Else?

While we understand it may be difficult, we ask you to be as thorough and accurate as possible when applying on someone else’s behalf. Please use the information of the individual who will be attending treatment. If you do not know specific information, or if you have any questions or concerns as you are filling out the questionnaire, please feel free to call us directly at 1 (806) 412-4721.

Your Application is Confidential

Any information submitted is transmitted through a secure connection and stored on HIPAA-compliant servers. We take your privacy very seriously. At Stages of Recovery, we are committed to protecting your personal information.

If you want to read more about our privacy policy or how we handle your medical records, you can read our comprehensive privacy policy here.

COMPLETE THIS FORM

Personal Information
Which location are you applying for?*
Which services are you interested in?*
Who is filling out this form?*
- Yourself
- Other contact
Your Name and Relationship to the Applicant?
Have you been speaking to someone at Stages of Recovery regarding admission?*
Their name?
Are you a former client of Stages of Recovery?*
- Yes
- No
Name (as shown on your ID)*
First Last
Name you Prefer to be Called (if different than above)
First
Date of Birth*
MM slash DD slash YYYY
Age*
Please enter a number from 16 to 99.
Gender Identity*
Marital Status*
T-Shirt Size*
Adult Unisex Sizes Available
Phone*
Email*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Social Security Number
Our site uses SSL encryption, so your information is safe and stored confidentially.
Employment History*
- Applicant is currently employed
- Applicant has been employed in the last six months
- Applicant has been employed in the last year
- Applicant has been employed in the last two years
- Applicant has no employment history in over two years
Describe employment history including dates and industry:*
What prevented employment during the last two years?*
Emergency Contact: First and Last Name*
Emergency Contact: Phone Number*
Emergency Contact: Relationship to Applicant*
Do you have a valid Driver's License, State ID or Passport?*
- Yes
- No
If Possible, Upload Pictures of the Front and Back of Your Identification (license, ID, etc.)
Drop files here or

Max. file size: 50 MB, Max. files: 2.
Insurance Information
Who is the insurance policy holder?*
- None - I Will Be Cash Pay
- None - I Need Help Getting Insurance
- Self
- Parent
- Spouse
- Other
IMPORTANT PLEASE READ:*
YES, I have read the statement below and I am interested in finding out if I qualify for health insurance through the comprehensive health care reform law enacted in March 2010.
Stages of Recovery is a PRIVATELY funded program - it is NOT a state funded or FREE program. Program fees can be in excess of $15,000.

You have selected that you DO NOT have health insurance, and you can NOT afford the cash pay rate of our program. You may qualify for health insurance through ACA, PPACA, or “Obamacare”.

A comprehensive health care reform law enacted in March 2010 (sometimes known as ACA, PPACA, or “Obamacare”) and has 3 primary goals:
1) Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level (FPL). If your income is above 400% FPL, you may still qualify for the premium tax credit in 2022. If your income is at or below 150% FPL, you may qualify to enroll in or change Marketplace coverage through a Special Enrollment Period.
2) Expand the Medicaid program to cover all adults with income below 138% of the FPL. (Not all states have expanded their Medicaid programs.)
3) Support innovative medical care delivery methods designed to lower the costs of health care generally.
Policy Holder Name*
Policy Holder's Date of Birth?
MM slash DD slash YYYY
Phone*
Is the policy holder's address the same as the client's above?
- Yes
- No
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Insurance Company Name (include State)
Insurance ID #
Insurance Group #
Insurance Phone #
If possible, upload a picture of the front and back of your insurance card:
Drop files here or

Max. file size: 50 MB, Max. files: 2.
Is the applicant covered under any other insurance policy? (Examples: Employer Plan, Parent's Insurance, Spouse's Insurance, Medicaid/Medicare, Marketplace Plan)*
- Yes
- No
By marking "no", you understand the cost of treatment may increase if a secondary policy exists (or is obtained in the future without prior discussion with Stages of Recovery), but is not disclosed*
- Yes
- No
Which type of policy is it?*
- Through an Employer
- Through a Parent
- Through a Spouse
- Through the Marketplace
- Through Medicaid/Medicare/State Funded Program
- Other
Substance Abuse History
Please be as thorough as possible. Input information of up to three substances you are currently using.
What led you to seek treatment now?*
Have you been in recovery before?*
- Yes
- No
What was the longest amount of time clean?
Are you currently in substance use treatment (Inpatient or Outpatient)?*
- Yes
- No
Name of current substance use treatment facility?
Level of care at current substance use treatment facility (check all that apply)
- Detox
- Residential
- Partial Hospitalization (PHP)
- Intensive Outpatient (IOP)
- Unknown
- Other
If other, please specify:
Date of admission at current substance use treatment facility?
MM slash DD slash YYYY
Expected date of discharge at current substance use treatment facility?
MM slash DD slash YYYY
What level of care has been billed to your insurance company by this treatment facility on your behalf? Check all that apply.
- Detox
- Residential
- Partial Hospitalization (PHP)
- Intensive Outpatient (IOP)
- Unknown
- Other
If possible, upload a copy of the medical records and face sheet from this facility.
Drop files here or

Max. file size: 50 MB.
Have you been to any substance use treatment in the past (Inpatient or Outpatient)?
- Yes
- No
Name of previous substance use treatment facility?
Level of care at previous substance use treatment facility? Check all that apply.
- Detox
- Residential
- Partial Hospitalization (PHP)
- Intensive Outpatient (IOP)
- Unknown
- Other
If other, please specify.
Date of admission at previous substance use treatment facility (or estimate)?
MM slash DD slash YYYY
Date of discharge at previous substance use treatment facility (or estimate)?
MM slash DD slash YYYY
Have you been to any other substance use treatment in the past - not currently (inpatient or outpatient)?
- Yes
- No
Name of previous substance use treatment facility?
Level of care at previous substance use treatment facility (check all that apply)?
- Detox
- Residential
- Partial Hospitalization (PHP)
- Intensive Outpatient (IOP)
- Unknown
- Other
If other, please specify:
Date of admission at previous substance use treatment facility (or estimate)?
MM slash DD slash YYYY
Date of discharge at previous substance use treatment facility (or estimate)?
MM slash DD slash YYYY
Have you been to any other additional substance use treatment in the past - not currently (inpatient or outpatient)?
- Yes
- No
Name of additional previous substance use treatment facility?
Level of care at previous additional substance use treatment facility (check all that apply).
- Detox
- Residential
- Partial Hospitalization (PHP)
- Intensive Outpatient (IOP)
- Unknown
- Other
If other, please specify:
Date of admission at additional previous substance use facility (or estimate)?
MM slash DD slash YYYY
Date of discharge at previous substance use treatment facility (or estimate)?
MM slash DD slash YYYY
What caused your last relapse?
Substance*
Age of first use*
How often do you use this substance?*
Average dose*
Preferred route of administration*
Last Use*
MM slash DD slash YYYY
Do you need to add more substances?
- Yes
- No
Substance
Age of first use
How often do you use this substance?
Average dose
Preferred route of administration
Last Use
MM slash DD slash YYYY
Do you need to add another substance?
- Yes
- No
Substance
Age of first use
How often do you use this substance?
Average dose
Preferred route of administration
Last Use
MM slash DD slash YYYY
Do you have any other process addictions of concern?
- Gambling
- Sex or Porn
- Video Games or Social Media
- Fitness or Working Out
Select all that apply. Or leave blank.
Mental Health
Are you currently in mental health treatment?*
- Yes
- No
Name of current mental health treatment facility?
Date of admission at current mental health treatment facility?
MM slash DD slash YYYY
Expected date of discharge at current mental health treatment facility?
MM slash DD slash YYYY
If possible, please upload clinical documentation of mental health proficiency to participate in substance use treatment?
Max. file size: 50 MB.
Have you ever been in mental health treatment before (inpatient or outpatient)?
- Yes
- No
Name of previous mental health treatment facility or mental health provider (psychiatrist, therapist, etc.)?
Date of admission at previous mental health treatment facility or mental health provider (or estimate)?
MM slash DD slash YYYY
Date of discharge at previous mental health treatment facility or mental health provider (or estimate)?
MM slash DD slash YYYY
Have you been to or participated in any other mental health treatment (inpatient or outpatient)?
- Yes
- No
Name of previous mental health treatment facility or mental health provider (psychiatrist, therapist, etc.)?
Date of admission at previous mental health treatment facility or mental health provider (or estimate)?
MM slash DD slash YYYY
Date of discharge at previous mental health treatment facility (or estimate)?
MM slash DD slash YYYY
Have you ever had any previous psychiatric diagnosis? (depression, ADD, bipolar, PTSD)?*
- Yes
- No
Please list any psychiatric diagnoses:
Do you have a history of trauma?*
- Yes
- No
Have you ever had issues with disordered eating?*
- Yes
- No
Describe disordered eating behavior(s):
Medical History
Answers will not necessarily disqualify you from treatment. These are only to better understand how we can best meet your specific needs.
Do you have any history of withdrawal symptoms?*
- Yes
- No
Please explain previous experience with thdrawal symptoms:
Have you ever been on Anti-Craving medications? (Vivitrol, Naltrexone, Campril, and/or Antabuse)?*
- Yes
- No
Do you feel like you need to be on them?
- Yes
- No
Are you currently on Suboxone or Methadone maintenance?*
- Suboxone
- Methadone
- No
Do you have any medical conditions?*
- Yes
- No
Please Explain
Have you been hospitalized in the past 30 days?*
- Yes
- No
Please Explain
Any physical limitations to activities of daily living (medical devices, dietary restrictions, etc.)?*
- Yes
- No
Please Explain
Allergies (medication/food/environmental/seasonal)?*
- Yes
- No
Please Explain
Are you currently prescribed any medication?*
- Yes
- No
Please list medications and dosages
Please upload a picture of the bottle of each of your prescribed medications.
Drop files here or

Max. file size: 50 MB, Max. files: 10.
Emotional/Behavioral Risk Screening
Answers will not necessarily disqualify you from treatment. These are only to better understand how we can best meet your specific needs.
In the past month, have you wished you were dead or wished you could go to sleep and not wake up?*
- Yes
- No
In the past month, have you actually had any thoughts of killing yourself?*
- Yes
- No
In the past month, have you been thinking about how you might do this? (e.g. "I thought about taking an overdose, but I never have made a specific plan as to when, where, or how I would actually do it...and I would never go through with it.")
- Yes
- No
In the past month, have you had these thoughts and had some intention of acting on them? (as opposed to "I have the thoughts but I definitely will not do anything about them.")
- Yes
- No
In the past month, have you started to work out the details of how to kill yourself? Do you intend to carry out this plan?
- Yes
- No
Have you ever done anything, started to do anything, or prepared to do anything to end your life? (e.g. collected pills, obtained a gun, gave away valuables, wrote a will or suicide note; took pills but didn't swallow any, held a gun but changed your mind or it was grabbed from your hand, went to the roof but didn't jump; or actually took pills, tried to shoot yourself, cut yourself, tried to hang yourself, etc.)*
- Yes
- No
Was this in the past three months?
- Yes
- No
Do you have a history of self-harm behaviors?*
- Yes
- No
Describe previous self-harm behavior:
Do you have anger issues?*
- Yes
- No
Any history of violence towards another individual?
- Yes
- No
Describe previous instances of violence towards another individual:
Legal Issues
Answers will not necessarily disqualify you from treatment. These are only to better understand how we can best meet your specific needs.
Are you currently on probation?*
- Yes
- No
Please specify which county and state.
Do you have any active warrants you are aware of?*
- Yes
- No
Please specify the charges, and the county and state of the warrant.
Are you a sex offender?*
- Yes
- No
Applicant understands Stages of Recovery may run a national sex offender search during the application process.
Which State(s) are you Registered in?
Any additional legal issues?*
- Yes
- No
Please explain
Are you a participant of any Specialty Court (Drug Court, Family Court, Veterans Court, etc. )*
- Yes
- No
Which Specialty Court?*
Who is your Judge?*
Which County is this in?*
General
How did you hear about us?*
- Referred By A Treatment Center/Sober Living/Recovery Professional
- Referred By A Doctor/Counselor/Legal Counsel
- Facebook
- Internet Search
- Word of Mouth
- I am a Former Client
- Other
Name of Treatment Center/Sober Living/Recovery Professional?*
Name of the individual who referred you?*
Name of the person and their position at the treatment facility who referred you?*
Would you mind sharing the name of the person you heard about us from?
Their Phone Number:
Their Email:
This field is hidden when viewing the form
Name of Doctor/Counselor?*
City and State Where They Practice?
Please Specify:
Which one?*
- Google Search Result
- Google Maps/Google My Business Listing
CAPTCHA
This field is hidden when viewing the form
Name
First Last
This field is hidden when viewing the form
Date
MM slash DD slash YYYY
This field is hidden when viewing the form
File
Max. file size: 50 MB.

READY FOR RECOVERY? WE’RE READY FOR YOU.

We’re committed to fostering unbroken recovery. We provide treatment for addiction and dual diagnosis that is both life-long and life-changing. At Stages of Recovery, our continuum of care helps individuals struggling with addiction become the people they were meant to be.

If you’re looking for a safe recovery program for yourself or someone you know, there is hope. Call us today.

Call Us Today: (806) 412-4721

Apply to Stages

of Recovery

Do you or a loved one need treatment for addiction and/or dual diagnosis?

Answering Our Questions Accurately Will Help Us Help You

Save Time and Money by Verifying Insurance While You Apply

Filling Out the Application for Someone Else?

Your Application is Confidential

COMPLETE THIS FORM

Personal Information

Insurance Information

Substance Abuse History

Mental Health

Medical History

Emotional/Behavioral Risk Screening

Legal Issues

General

READY FOR RECOVERY? WE’RE READY FOR YOU.