Admission Application

Do You Need Help? Does Someone You Know Need Help?

If you or someone you know needs help, call the Chemical Dependency Recovery Center for a free confidential assessment. Our staff will answer your questions about our alcohol and drug treatment programs, Chemical Dependency disorders and their effects on the family. We can also make referrals to interventionists and other recovery services as needed.

Call us now at: (877) HOAG-CDC (462-4232)

Admissions Process:

When you call, you will speak with a staff member who will guide you through a brief, confidential inquiry. A more thorough telephone assessment may be completed at the same time, or scheduled to occur within 24 hours of your initial inquiry.
Upon completion of the assessment, our treatment team will determine the most appropriate level of care for you, either at our center or elsewhere.
When treatment is recommended at the Hoag Chemical Dependency Recovery Center, an admission date will be scheduled. Our Care Coordinator will be available to answer questions you may have prior to admission.

If you are unable to contact us at a time that is convenient for you, please complete the online admission application below. One of our Care Coordinators will contact you within 24 hours to continue the process

Chemical Dependency Center Admissions Application Please complete this form and submit online or print and fax to (949) 764-8185
Your Name:	Street Address:
City:	State:	Zip:
Email:	Relationship to patient:
Home Phone:	Mobile Phone:	Work Phone:

Name:

DOB:

Gender: MaleFemale

Marital Status:
MarriedSingle

The substance use problem includes (check all that apply):

Have you had previous treatment(s) for Substance Abuse?:

AlcoholPrescription MedicationsOther Drugs
List of other drugs:

YesNo
If Yes, please specify when and where:

Have you ever been hospitalized for Psychiatric treatment(s):
YesNo
If Yes, please specify when, where and what/why:

Are you currently under the care of:
Psychiatrist?Psychologist?Therapist/Counselor?

Have you been hospitalized for any reason in the past 90 days?
YesNo
If Yes, please specify when, where and what/why:

Are you currently taking prescribed medications?
YesNo
If Yes, please specify:

InsuranceSelf Pay

Insurance Company:	Policy/ ID#:
Policyholder:	Relationship to Patient:	Policyholder DOB:

Employer/ Group Name:	Group #:	Benefits Phone:

Submit Application

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