Vinland National Center Application for Residential Treatment

Full Legal Name

Date of Birth

Social Security #

Primary Phone #

Secondary Phone #

Address

County

Marital Status

Race

Enrolled in a Tribe?

Name of Tribe

Do you receive SSI or SSD?

How much?

Emergency Contact Name

Relationship

Phone #

Guardian
YesNo

If yes Name of Guardian

Guardian Phone #

Please attach/send copy of guardian paperwork.

Commitment Status

Full Commitment

Stay of Commitment

Please attach/send copy of commit paperwork.

Probation
YesNo

Probation Officer Name

PO Phone#

County

Clinic Name

Dr. Name

Clinic Phone #

Clinic Fax#

Mental Health Therapist Name

Clinic Name

Tel. #

Insurance Company

ID #

Please attach a copy of insurance card

Insurance Company

ID #

Please attach a copy of insurance card

Insurance Company

ID #

Please attach a copy of insurance card

Does Client have a Rep-Payee?
YesNo

Rep-Payee Name

Rep-Payee Phone