Residential
Treatment Application
“We’re a Good Family to Know.”
4066 Dunnica
St. Louis, Missouri 63118
Phone: 314-833-6155
FAX: 314-833-6159
ADVANCE@PFH takes a holistic strengths-based approach tailoring therapeutic interventions to individual
strengths, needs, abilities, and preferences. ADVANCE@PFH provides a full continuum of care for substance
use and co-occurring disorders for young adults’ ages 18-26 years old.
You may be asking, “Why do I need to apply for treatment?” ADVANCE@PFH strives to turn no one away.
However, treatment funds for the uninsured are limited. You can help us expedite the application and
admission process by answering all questions to the best of your ability and sending the completed application
back to us as soon as possible.
ADVANCE@PFH is committed to doing our best to ensure prompt access to treatment prioritizing admissions of
applicants based on need and residential bed availability.
Reaching out for help takes courage; no matter the life circumstances surrounding your investment in
treatment at this time; participation in ADVANCE@PFH is strictly voluntary.
Should it be determined that ADVANCE@PFH is not a good fit for you; our Staff will work with you to find an
appropriate alternate treatment program to help meet your needs.
What you will need to complete the application process:
1. ADVANCE@PFH Participant Handbook
a. Our Handbook will provide a basic awareness of treatment expectations.
i. A willingness to participate in structured therapeutic activities is a key aspect of
maximizing the benefit of treatment for you as well as for other program participants.
2. Completed Application
a. Submit to ADVANCE@PFH.org or Fax to: 314-833-6159.
3. Verification of Missouri Residency - Photo Copy of ID
a. This is necessary as funds available to assist in paying for treatment services are currently
limited to State of Missouri Residents.
Upon receipt of your application, you will receive a phone call and/or email to schedule a phone or in-person
Screening if this was not completed upon initial contact.
Thank you for your interest in ADVANCE@PFH and if you have any questions feel free to email us at
ADVANCE@PFH.org or call us at 314-833-6155.
Congratulations on taking the first step toward Recovery!
Shelley Stretch
Clinical Supervisor
CONFIDENTIAL
Applicant Information
;
(Last Name)
(Primary Phone#)
(First Name)
(Secondary Phone#)
(MI)
(Nick Name OR Preferred Name)
(Email Address)
(Street Address)
(Birth Date MM/DD/YY)
(City)
I give permission for staff to contact me by:
(State)
Phone
(Zip Code)
Email
Emergency Contact Information
(Last Name)
(Primary Phone#)
(First Name)
(Secondary Phone#)
(Relationship to Applicant)
May we
Contact?
(Email Address)
Yes
Who referred you to ADVANCE@PFH?
(Referral Last Name)
(Referral First Name)
(Referral Relationship to Applicant)
May we
Contact?
(Referral Phone#)
(Referral Email Address)
Yes
If Female, are you Pregnant?
Yes
No
Have you ever used IV Drugs?
Yes
No; Last Date of IV Drug Use:
No
Unknown
Are you having any thoughts of harming yourself or others at this time?
Yes
No
If you are at immediate risk; please call 911
Have you ever attempted suicide?
Yes
No If yes, Date of last attempt?
Have you ever received treatment for a Substance Use Disorder?
Outpatient?
Yes
No; How many times?
Residential?
Yes
No; How many times?
In a Hospital?
Page 2 of 5
Yes
Yes
No; How many times?
No; How many times?
No
Date of last treatment:
Date of last treatment:
Have you ever received treatment for a Mental Health Disorder?
Outpatient?
Yes
Yes
No
Date of last treatment:
Date of last treatment:
No
CONFIDENTIAL
Are you currently taking prescribed or over-the-counter medications?
Yes
No
If yes, please list:
Will you be able to bring 14-21 days of medications with you to treatment?
Yes
Please share what you expect to gain from treatment at ADVANCE@PFH:
Do you feel ready to make changes in your use of drugs and/or alcohol? Why or Why Not?
If you have been in Substance Use Treatment/Recovery previously; what worked for you?
Do you have any preferences/needs that would assist you in engaging fully in Recovery?
What obstacles do you foresee that might prevent you from enjoying a successful Recovery?
Page 3 of 5
No
CONFIDENTIAL
ADVANCE@PFH is a Tobacco Free treatment environment; Nicotine Replacement Therapies
coupled with other Tobacco Cessation tools are readily available to assist program participants.
Do you use Tobacco Products?
Yes
No
If you currently use tobacco; are you willing to adhere to Tobacco Free Guidelines and participate in
Tobacco Cessation programming?
Yes
No
Do you need assistance with transportation to and from treatment?
Yes
No
Who do you currently live with?
Do you have a significant Other?
Yes
No
Is he/she willing to support you in treatment participating in therapeutic sessions?
Yes
No
Will any of your family members be willing to support you and participate in therapeutic sessions?
Yes
No
Income & Insurance
What is your monthly income?
How many people are you responsible for supporting with your income?
If determined eligible, will you be willing to apply for Medicaid?
Yes
No
If ineligible for Medicaid, will you be willing to apply for insurance through the Health Insurance
Marketplace?
Yes
No
Is there anything else about yourself that would be important for us to know about you that you
would like to share?
Page 4 of 5
CONFIDENTIAL
Certification of Information
I do hereby acknowledge that the information provided herein is true and accurate. I understand that I will be
responsible for providing verification of Missouri Residency if approved for admission to ADVANCE@PFH. I
understand that my financial situation will be reviewed at 90 day intervals. If my financial situation changes, I
agree to notify Preferred Family Healthcare within 30 days.
I have read the Participant Handbook. I understand that ADVANCE@PFH is a Tobacco Free environment and
that Nicotine Replacement Therapies and other tobacco cessation tools will be made available to me during my
treatment stay; I am willing to be Tobacco Free during my treatment episode.
I recognize that I will undergo a full Assessment upon admission to PFH and if at that time it is determined
that an alternate level of care is more appropriate; staff at ADVANCE@PFH will assist me in accessing
applicable treatment services. If admitted to PFH I am willing to do my best in order to get the maximum
benefit from treatment.
__________________________________________
Applicant Signature
__________________________________________
Guardian Signature (if applicable)
Page 5 of 5
_________________________
Date
_________________________
Date