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Counseling & Treatment

Applying gender-responsive, healing-centered interventions, Phoenix Counseling Solutions offers an intensive outpatient treatment program certified by the Ohio Department of Mental Health and Addiction Services.

Treatment Services Application:

First Name

Last Name

Company

Phone

How many will you be?

Is this your first time attending?

Yes

Recovery Journey Information:

Do you identify as?

Alcoholic

Drug Addict

Other/I Don't Know

Currently in treatment?

Yes

If in treatment, name and location of facility:

Drug(s) of choice?

Date of Last Use:

Employment Information:

Are you currently employed?

Yes

Actively Seeking Employment

I.O.P. is 9:00AM to 12:00PM on Monday, Wednesday and Friday. Are you able to commit with your schedule?

Yes

Legal Information:

List pending charges, cases and/or warrants:

On Probation/Parole?

Probation

Parole

Inactive Probation

No Parole/Probation

Probation/Parole Officer Name and Number:

Medical Information:

List of all medical and/or psychiatric conditions:

List all current medications:

Are you on medically- assisted treatment?

Suboxone

Methadone

Vivitrol

None

Emergency Contact:

First Name

Last Name

Relationship

Phone

Document Upload:

1.) Assesment

Upload File

Upload supported file (Max 15MB)

2.) Certification of Completion of Treatment

Upload File

Upload supported file (Max 15MB)

3.) Release of Information for other Care Providers (i.e., case managers, probation officers, counselors, etc.).

Upload File

Upload supported file (Max 15MB)

Thank you for your submission.

Jordan CRC

Empowering Female Survivors of Human Trafficking, Drug Addiction, Re-entry and Behavioral Health.

Email: info@jordan4change.com

Phone: (216) 441-2496

Donate: CLICK HERE

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