On-Line Admissions Application

In order to better serve you, we require some information about you. As we customize a nutritional plan for each individual, we need to know the exact nature and desired outcome for your visit at The Essesnce Center. Information submitted on this form will be held in the strictest confidence by our staff. None of this information will be provided to any outside source without your explicit consent. Please be as thorough as possible. Once this information is received, a staff member will contact you to make arrangements for your stay with us.

•= Required Fields

PERSONAL INFORMATION

• First Name :	•Last Name:
I prefer to be called:	•Email:

MAILING ADDRESS	PHYSICAL ADDRESS (Same as Mailing Address)
Address:	Address:
City: St: Zip:	City: St: Zip:

•Evening Phone: (XXX-XXX-XXXX)	•Day Phone: (XXX-XXX-XXXX)

•Sex: Male Female	Date of Birth: / /

PLEASE INDICATE THE ISSUES YOU WISH TO RECOVER FROM:

Please tell us what it is you are wishing to overcome (Check all that apply):

Alcohol Dependency	Anxiety
Drug Dependency	Sleep Disorder
Food Addictions	Chemical Imbalances
Eating Disorder-Bulemia	Weight Problems
Eating Disorder-Anorexia	Fibromyalgia
Nicotine Addiction	Chronic Fatigue Syndrome
ADD/ADHD	Chronic Poor Health
Depression	General Detoxification & Cleansing

•Please provide us with any additional information that will help us help you, especially if your issue is not listed above.

PREVIOUS COUNSELING / TREATMENT EXPERIENCE

Please tell us what you have tried in the past (check all that apply):

Treatment Center (In-Patient)	How many times?
Treatment Center (Out-Patient)	How many times?
Counseling/Therapy	For how long?
12-Step Groups	For how long?
Alternative Health Care	What type?
Herbs/Supplements	Please list:
Other	Please list:
I haven't tried anything yet.

Health Information

• Do you have any immediate health concerns? Yes No	If "Yes", please describe:
Do you have any physical disabilities? Yes No	If "Yes", please describe:
•Do you have any long-term illnesses? Yes No	If "Yes", please describe:
•Have you ever had life-threatening symptoms during withdrawal? Yes No	If "Yes", please describe:
Do you have any dietary restrictions? Yes No	If "Yes", please describe:
Do you have any allergies? Yes No	If "Yes", please describe:

SIGNATURE

For your benefit, it is important that the above information be truthful and that you not omit anything. By clicking "I Agree" below, you are agreeing that you understand that your program at The Essence Center will be based on the information that you are providing here and that this information is true and complete. You are also acknowledging that The Essence Center has the right to, at its discretion, refuse admissions to any individual who they do not feel is physically, mentally or emotionally able to participate in our programs.

YOUR APPLICATION WILL NOT BE PROCESSED WITHOUT YOUR AGREEMENT TO THIS STATEMENT

• I AGREE

RESERVATION AND REFUND POLICY

Payment in full is due to hold your reservation. All fees are non-refundable and non-transferable if cancelled within 14 days of reservation date. An administrative fee of 10% of reservation total, including all services that have been reserved will be charged for cancellations or changes in reservations (including date changes) made more than 14 days in advance reservation date. All accommodations and packages are sold on a first-come, first-served basis. Prices subject to change without notice. Reservations based on availability.

YOUR APPLICATION WILL NOT BE PROCESSED WITHOUT YOUR AGREEMENT TO THIS POLICY

• I AGREE

MISCELLANEOUS

How did you first find out about The Essence Center?
If Web Site or Search Engine, please name:

When you have finished filling in the above information, please click on the "Submit Form" button below to send us your Application. By submitting this form, you are acknowledging that you have read the information presented here, all information entered is true and correct and your are agreeing to the above policies.