If you feel this is an emergency, please call 911 

Pre-Admissions Inquiry           

Please provide some basic information which will help us better understand your needs. All information is held in a secure format absolutely confidentially.

* Required fields

Name of Client: (First, Middle, Last)*

Contact (if you are completing this form for someone else, please enter your name):

Email:*

Phone:*

Sex:*
Male Female

Describe the dependency, addictions and behavior to the best of your ability:*
Detox Needed? Yes ____ No_____      Is An Intervention Needed? 

Is the individual in treatment, or had treatment in the past. If yes, please explain below:
         Please give us an idea of when the patient may want to come into treatment? 

Please explain; current physical & emotional conditions: Stress/Panic Attacks, Obsessive Compulsive Behavior; Anger-Pain *

Is the individual taking any prescription medication:
If yes please specify dosage and frequency:

Why do you think there is a problem?: When and why do you think the problem began?   Patient's occupation is-



Thank you for your help, upon receipt and review we will respond to you promptly.  If your situation is life threatening, please call 911.  

In the meantime, please feel free to call our Center for answers to any questions you may have about the program

The Brain Health & Recovery

Copyright © 2000, AAERetreat / The Crosby Recovery Centers. All rights reserved.
AA&E Retreat/ Crosby Centers are recognized around the world providing affordable effective individualized programs.
The success of our programs have given patients their best opportunity to reclaim their life and achieve sustained recovery.
We are a private-pay facility. Forensic Doctors And Specialists  Professionals Fully Licensed by the State of California.
THE COMPREHENSIVE WHOLE PERSON 'holistic' TREATMENT