September 24, 2017

   
 
 
Date:*
Name:*
Current Address:*
Phone Number:*
Birthdate:*
Age:*
Marital Status:*
Emergency Contact:*
Relationship:*
Phone Number:*
Drugs of Abuse:*
Date of Last Use:*
Have you ever been to treatment? If so, where and when:*
Current medical issues:*
Current prescriptions:*


 
FERN HOUSE DRUG/ALCOHOL/ MEDICATION POLICY:
Fern House has ZERO tolerance for and alcohol or drug use. Fern House also prohibits the use of any narcotic or non-narcotic prescribed medications that may be mind or mood altering.

PAYMENT:
I understand that upon admission to the Fern House residential program I must pay a one-time administrative fee of $50.00 AND the first week of rent which is $203. Total due upon admission is $253.00.