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(801) 851-5260

About
Levels of Care
Clinical
For Clients
For Families
Admissions
Trainings
Contact
(801) 851-5260

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Client Application

Submit Your Application and Learn More About Balance House

Client Applicationbalancehouse2023-04-03T11:40:47-06:00

Client Application

Basic Information
Application Date:
MM slash DD slash YYYY
Expected to Enroll
Client Name*
Address
City, State, Zip
Client Cell Phone
Client Email Address*
Age
DOB
MM slash DD slash YYYY
SSN
Highest level of education completed
Military Service
- Yes
- No
Is client currently enrolled in school?
- Yes
- No
Is client currently employed?
- Yes
- No
Current Occupation
Legal problems? Past or present.
- Yes
- No
Please explain
Is there anything else that we should know that is not listed above?
Referral Information
How did you hear about the Balance House Programs?
Referral Source Name
Phone Number
Email Address
Emergency Contact Information
First Name
Last Name
Relationship to Client
Address
City
State
Zip Code
Cell Phone
Email Address
Father's Information
First Name
Last Name
Address
City
State
Zip Code
Cell Phone
Email Address
Mother's Information
First Name
Last Name
Address
City
State
Zip Code
Cell Phone
Email Address
Marital Status of Parents
Are Parents Divorced/Separated
If yes, when?
Are there any special circumstances?
Has divorce/separation been an issue for your son?
Treatment
What specific events precipitated enrollment into EVNSQ and the Balance House Program?
What are your specific objectives for you and your son while he is enrolled in the EVNSQ and the Balance House Program? (I.e. Lifeskills, therapy, sobriety, self-esteem, identity, independence.)
Does client use alcohol and/or drugs on a daily basis?
- Yes
- No
If so, what substances and how often?
Tobacco Use:
- Yes
- No
If so, what kind and how often?
History of seizures or blackouts
Has your son been in treatment before? If yes, please indicate places and dates
Please indicate areas in which you have seen your son struggle
History of trauma/abuse/being bullied?
Describe any depressive features, mood swings, or isolation
History of physical aggression?
Has client ever been under the care of a psychiatrist or therapist?
- Yes
- No
If yes, when and what was the nature of the treatment?
Therapist Name
Phone Number
Email Address
Psychiatrist Name
Phone Number
Email Address
Family history of mental or emotional illness/substance abuse?
Has client been administered psychological testing in the past?
- Yes
- No
If yes, when was it administered
If yes, May we obtain a copy?
- Yes
- No
What other interventions have you tried in the past?
Medical
Has the client been vaccinated for COVID-19?
- Yes
- No
If yes, please provide brand and dates of immunizations received:
Brand
Date
MM slash DD slash YYYY
Any current or past history of chronic pain?
Are there any current/past medical issues that need to be assessed by our medical staff?
Have you ever had a head injury (TBI)?
Are there any known allergies?
Medical Information
Is the client currently taking any medications?
- Yes
- No
Please note that you will need to supply a copy of the doctor’s prescription or original bottle to the program for any continuing medications
Name of Medication(s) EXACTLY as indicated on the package/prescription (am/pm dosage)
Has client been taking medication(s) long enough to be stabilized?
Has client ever been on Medication Assisted Therapy (MAT)? (Subutex, Suboxone, Methadone
Please list any previous medications prescribed for emotional, behavioral, or substance abuse issues, attention deficit and the approximate date and the positive or negative result of each:
Please indicate history in regards to taking medications
Are there any potential risks such as dehydration or irregular food intake associated with medications the client is taking?
- Yes
- No
If yes, please explain:
Do any medications the client is taking cause sun sensitivity?
- Yes
- No
If yes, list medications:
Has the client recently been taken OFF any medications? If so, please list medications and circumstances:
Is the client allergic to any medications?
- Yes
- No
If yes, please list the medications and the allergic reactions:
For drugs that require a stabilization period we will need confirmation by the client’s prescribing physician
Is client sexually active?
- Yes
- No
Are there any physical reasons why client might have difficulty participating in our program?
- Yes
- No
If yes, please explain:
History of eating disorder/ disordered eating?
Other Information
How would you describe your present health?*
- Excellent
- Good
- Fair
- Poor
Name
This field is for validation purposes and should be left unchanged.

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5170 Highland Dr.
Holladay, UT 84117
T: +1 (801) 851-5260

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