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About
Programs
Admissions

Admissions

Get Started On Your Way To Recovery

Prior to admissions and intake into Mississippi Family Centers for Recovery, we would like to get to know you and your situation better. Please be sure to complete the entire form, from start to finish. The more information you provide, your possibility of joining our program increases.

Remember, we’ve been there. We know exactly what you’re going through. There is no need to hide anything, and you can rest assured that your information will not be shared.

Name*
First Last
Best Contact Phone Number*
Email
Home Address*
Street Address Address Line 2 City State ZIP Code
Date of Birth*
MM slash DD slash YYYY
Last 4 of SSN*
Insurance Company
Insurance Phone Number
Group ID*
Member ID*
Name of Insured
Relationship To You
Are You Currently Pregnant?*
- Yes
- No
If Yes, How Far Along Are You?
Do You Have Any Dependent Children?*
- Yes
- No
If So, Who Has Legal Primary Custody of Children?
Children's Names AND Dates of Birth
Last 2 Years of Reported Income (On Your Tax Returns)
Last Year's Reported Income*
Previous Year's Reported Income*
Are You Currently Using Substances and/or Alcohol?*
- Yes
- No
If Yes, Please List Which Substances and How Often
Drugs/Substances Of Choice*
Last Date Of Use. What Substances and How Much?*
Any Medical Issues, Physical Needs, Mental Health Diagnosis, Behavioral Issues Etc?*
Have You Ever Had A Seizure?*
- Yes
- No
If Yes Please State When And How Often
Any Past Or Current Legal Charges*
- Yes
- No
What Are The Charges?
Have You Ever Attended Treatment Previously?*
- Yes
- No
If Yes, Please List Each Treatment Stay And Length Of Stay
Have You Ever Experienced Hallucinations (In The Past Or Recently)?*
- Yes
- No
If Yes, Please List Them And Their Current Status
Have You Ever Left Treatment Against Medical/Clinical Advice (AMA)?*
- Yes
- No
Do You Have Any Mental Health Diagnoses?*
- Yes
- No
If Yes, Please List Them And Their Current Status As Well As Any Medications Used For Them
In Your Own Words, Please Tell Us About Yourself And Your Situation/Story*
Minimum 100 Words

13181 Reece Bergeron Rd.

Biloxi, MS 39532

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