Santorini Women’s: Admission Form First Name *Last Name *Phone Number *Email Address *Date of Birth of Patient *DaySelect day12345678910111213141516171819202122232425262728293031MonthSelect month123456789101112YearSelect Year212621252124212321222121212021192118211721162115211421132112211121102109210821072106210521042103210221012100209920982097209620952094209320922091209020892088208720862085208420832082208120802079207820772076207520742073207220712070206920682067206620652064206320622061206020592058205720562055205420532052205120502049204820472046204520442043204220412040203920382037203620352034203320322031203020292028202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926Street Address *Apartment, suite, etcCityState/ProvinceZIP / Postal CodeCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre & MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweSex *FemaleOtherPrefer not to sayMartial Status *SingleMarriedDivorcedSeparatedLiving togetherWidow/WidowerDo You have Any of the Following Health Issues? (please check all that apply) *High blood pressureHeart diseaseLung IssuesHepatitisFungusNone of the above applyDo you take any medications? If yes, please list all below and the reason each was prescribed *Do you have any allergies? If yes, please list all below* *Have you had any past surgeries? *When was the last time you visited a doctor? *Do you drink/consume any of the following items? *CoffeeAlcoholTeaSmokeOtherOccupation *In case of an emergency, please list the name and phone number of your emergency contact *How did you hear about us *Luxury RehabsUSA Program AbroadThrough a Friend/RefferalCurrently in Greece or EUInternet SearchOtherThe next portion of these admissions will be more personal women questions. If you prefer to answer them when you arrive directly with a women intake counselor & Doctor, you can choose to skip or continue.SKIPCONTINUEAre you currently pregnant, postpartum, or breastfeeding? When was your last menstrual period?I would rather answer upon intakeWhat is your current method of contraception, if any (Birth Control)? Are you experiencing any gynecological concerns or chronic conditions (e.g., PCOS, endometriosis, fibroids)?I would rather answer upon intakeTo help us provide the safest and most supportive environment, please share if you have a history of physical, sexual, or emotional abuse, assault, or intimate partner violence. You may write 'yes,' or 'no,'I would rather answer upon intakeWhat is your current parenting status and custody arrangement for any dependent children? Is maintaining or reunifying with your children a primary goal of your treatment?I would rather answer upon intakeBeyond substance use, have you ever been diagnosed with or experienced symptoms of: PTSD, anxiety, depression, an eating disorder, or perinatal/postpartum mood disorder and or any other Dual Diagnosis ?I would rather answer upon intakeSome women use substances to manage weight or body image concerns. Have you ever used substances to suppress appetite, control weight, or cope with feelings about your body?I would rather answer upon intakeDescribe your current primary relationship(s) and living situation. Do you feel safe and supported there? Are any of your close relationships connected to your substance use?In any past treatment experiences, were there aspects that felt particularly unhelpful or unsafe as a woman? Were there any you found especially helpful?I would rather answer upon intake"In any past treatment rehab/detox experiences, were there aspects of the program that felt particularly enjoyable ? Were there any methods you would like us to customize into your program that we do not have?" If this is your first Rehab Center please write “This is my first time in Rehab” *Government ID *Drag and Drop (or) Choose FilesConsent *I read and accept the: Terms & Conditions.Submit Now
