Patient Admissions Application

Preliminary Admissions Application

Please call Admissions before completing this form.

Prospective Client Personal Information
First Name
Last Name
Street Address
City
State & Zip
Phone Number
Email
Pronouns
If you are NOT the client, please fill in the next section
First Name
Last Name
Street Address
City
State & Zip
Email
Phone Number
Relationship to client
Current Status
Please outline your current situation. Information about current or recent treatment and hospitalizations is especially helpful. This will give us the context for our more detailed conversation
How would you like your life to change through your involvement with Windhorse?
What medications are being prescribed currently, if any?
How did you hear about Windhorse?