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1-866-772-0267
1-866-772-0267

Embrace Application

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Step 1 of 7

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Student Information

Name*
Legal name (if different)
MM slash DD slash YYYY
Currently enrolled in school*
Currently employed*

Contact Info

Address*

Primary parent / sponsor information

Name*
Sponsor*
MM slash DD slash YYYY

Contact Information

Address

Employment Information

Secondary Parent/Sponsor

Name
Sponsor
MM slash DD slash YYYY

Contact Information

Address

Employment Information

Referral Informaton

Educational Information

Psychological History

Have you ever been diagnosed with a mental health disorder by a licensed professional (therapist, counselor, physician, etc)?*
Have you had any physical confrontations or altercations with others?*
Suicidality and Self-Injury​: Have you ever had thoughts of suicide, made a plan, or attempted suicide?*
Have you ever intentionally hurt yourself?*
Mood​: Do you experience symptoms of anxiety, depression, mood swings, etc.?*
Obsessions/Compulsions​: Do you experience recurrent thoughts or repeated behaviors that you have difficulty controlling?*
Lying, stealing, vandalism, dealing drugs, criminal activity​:*
Unusual Behaviors​ (current or past):*
Eating Issues​ (current or past):*
Isolation​: Do you struggle with isolation?*
Motivation​: Do you struggle to get out of bed in the morning and engage in the day?*
Substance-Related Issues​: Do you experience any alcohol, substance and/or dependency related issues?*
Other addictive patterns​ (eg: computer games, T.V., phone, internet, sex, gambling):*
Legal Problems​:*

Nutrition Information

Medical information

MM slash DD slash YYYY
Are there any known side effects of the medication?*
Do you manage medications appropriately and follow prescribed medication regimen without support from others?*
Do you have any dietary restrictions?*

Immunizations

Are you up-to-date on immunizations?*
Date of last immunization​:
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

Allergies/asthma​:

Do you carry an inhaler or epinephrine pen?*
Have you ever been hospitalized for allergies/asthma?*
I agree*

925 Pine Shore Drive

Brevard, NC 28712

1-866-772-0267

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