Raw Score for this Application: out of - %

Q1. Please enter the following: First Name, Last Name
First Name:

Last Name:

Q2. I am submitting an application to attend the CAP Respite Center because:

Q3. When was your treatment? (MM/DD/YY)

Q4. Where was treatment given?

Q5. What was the method of treatment (counseling, psychotherapy, medications, inpatient stay, outpatient services, etc.)? Please explain.

Q6. Have you been prescribed any psychotropic medications? If yes, what were they?

Q7. Are you currently taking any psychotropic medications (type(s) and dosage)?

Q8. Have you ever been treated for drug (recreational or prescribed) or alcohol abuse? If yes, what type of abuse is/was it?

Q9. When, Where and What was your treatment?