*To expedite admission to Turning Pointe, please have your attorney, CPS worker, or probation/parole officer contact us at 304-252-6783 or fax to 304-252-6796.

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Date *
Date
Name *
Name
Date of Birth *
Date of Birth
Address
Address
Phone *
Phone
Medicaid
Emergency Contact
Emergency Contact
Emergency Contact Phone
Emergency Contact Phone
Date of Last Drug Use 1:
Date of Last Drug Use 1:
Date of Last Drug Use 2:
Date of Last Drug Use 2:
Date of Last Drug Use 3:
Date of Last Drug Use 3:
Program Name and dates attended.
Circle One
Due Date
Due Date
If pregnant, you must provide a proof of pregnancy in order for this application to be processed.
Post-Partum: Baby's DOB:
Post-Partum: Baby's DOB:
Currently:
Please explain.