New Member Application

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How to Apply

Our intake process is designed to be transparent, supportive, and focused on your long-term recovery.

01

Initial Inquiry

Reach out to our admissions team or simply complete the New Member Application below.

02

Onsite Interview

Visit our facility for a face-to-face meeting with our professional staff to discuss the community standards and expectations.

03

Final Decision & Orientation

Once accepted, you will begin your orientation to the member environment.

Please complete all sections. If a question does not apply, write "N/A".

Preferred Start/Move-In Date:*

How did you hear about us?*

Personal Information

First Name:*

Last Name:*

Preferred Name/Pronouns:*

Date of Birth:

Month

Day

Year

Social Security Number:*

Phone Number:*

Email Address:*

Current Address:*

City, State, Zip Code:*

Emergency Contact Name:*

Emergency Contact Phone Number:*

Demographics

Gender:*

Race/Ethnicity:*

Primary Language:*

Marital Status:*

Veteran Status:*

Yes

Highest Level of Education Completed:*

Recovery Information

Primary Substance(s) of Use:*

Length of Sobriety:*

Date of Last Use:*

Have you completed a treatment program?*

Yes

If yes, please provide details below:

Treatment Center Name: *

Level of Care (Detox, Residential, PHP, IOP, OP):*

Dates of Attendance:*

Primary Counselor/Therapist:*

Facility Phone Number:*

Reason for Discharge/Completion Status:*

Are you currently attending meetings?*

Yes

If yes, how often:*

Do you have a sponsor?*

Yes

Sponsor Name & Phone Number:*

Medical & Mental Health

Do you have any diagnosed medical conditions?*

Yes

If yes, please explain: *

Are you currently taking any medications?*

Yes

If yes, please list medications: *

MAT (Medication-Assisted Treatment) Information

Are you currently enrolled in a MAT program?*

Yes

Medication Type:*

Prescribing Provider/Clinic Name:*

Provider Phone Number:*

Dosage & Frequency: *

Last Dose Taken: *

Insurance Information

Do you currently have health insurance?*

Yes

Insurance Provider:*

Policy Number:*

Group Number: *

Policy Holder Name: *

Relation to Policy Holder:*

Insurance Provider Phone Number:*

Employment & Financial Information

Are you currently employed?*

Yes

If yes, employer name: *

Work Schedule: *

Do you have a source of income?*

Yes

If yes, please describe:*

Legal Information

Are you currently on probation or parole?*

Yes

If yes, officer name and contact:*

Do you have any pending legal matters?*

Yes

If yes, please explain:*

Applicant Checklist (if applicable):

Photo ID

Insurance Card (front/back)

List of Current Medications

Emergency Contact Information

Relevant Legal/Probation Documents (if applicable)

Agreement & Signature:

Consent to Contact (optional): I authorize staff to contact the following provider(s) to coordinate care (e.g. counselor, prescriber, case manager):*

Release of Information: I understand that additional authorization forms may be required to release or obtain protected health information.

I certify that the information provided is true and accurate to the best of my knowledge.

Applicant Signature:*

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Date*

Month

Day

Year

Get in Touch

We are here to guide you through every step of your recovery. Reach out to our admissions team for a private consultation.

Phone: (512) 964-0410

Email: info@thecarsonhouse.com

First Name*

Last Name*

Email Address*

Phone Number*

Recovery Goals

Empowering Recovery, Building Community

3416 Primrose Trail Georgetown, TX 78628

info@thecarsonhouse.com | (512) 964-0414