We welcome you to MONARCH. Every woman and child is treated with dignity and respect. We’ll work hard to help you feel at home and wanted here. We’ll encourage your children to be themselves. We treat you as an individual, understanding you have your own unique issues, challenges and goals. To be considered for entry into our program, please complete the following application or download the form and send it to: (need address here).

Intake Application

- Select Type of Intake Residential Living Community Living
First Name:	Last Name:
Age:    Date of Birth:	Maiden Name:

Address:
City:	State:    Zip:
Phone:

Ethnic Background: - Select - White African American American Indian Asian Hispanic

Education: (years completed)

Emergency Contact:

Relationship:    Phone:

Are you pregnant? - Select - No Yes

If you answered Yes then how many weeks?

Have you established parental care?     - Select - I do not have any children No Yes

Are your children in DHS custody?     - Select - I do not have any children No Yes

Are your children coming with you to treatment? - Select - No Yes

If you answered Yes then how many children?

Do you have any history of IV drug use? - Select - No Yes

Last time you used IV:

Do you have HIV / AIDS? - Select - No Yes

What was your first drug of choice:

What was the route of usage:

When did you use last:

Comments:

Any Medical or Mental problems? - Select - No Yes   If Yes list below:

Currently taking any medication? - Select - No Yes   If Yes list Names and Dosages below:

Previous Drug Treatments? - Select - No Yes   If Yes (when / where/ Diagnosis) list below:

Previous Mental health Treatments? - Select - No Yes   If Yes (when / where/ Diagnosis) list below:

Are you court ordered or community sentencing? - Select - No Yes If Yes list your current Probation Officer- (Name / County / Phone) below:

Are you currently involved in a child welfare case? - Select - No Yes If Yes list your current child welfare worker- (Name / County / Phone) below: