Patient History Inpatient Admission Application We will contact you by phone or email within one working day of receiving your application. Step 4 of 6 Patient History Describe why child needs inpatient treatment. * Has child been assessed or treated in outpatient treatment? * YesNo Agency Name Counselor Name Agency Phone Is child pregnant? YesNo Is child an IV drug user? YesNo Is child on probation or parole? YesNo Parole Officer Name Parole Officer Phone Δ
