Admission Form

Please note that your information is saved on our server as you enter it. All saved information is fully encrypted to ensure safe storage of information.

Thank you for your interest in Mending Hearts, Inc. program. Completing this pre-screening form is the first step of the assessment process for you. Once completed, the pre-screening will be assessed for programs, funding and level of care. The turnaround time is approximately 48 hours, if no additional information is needed. When assessment is complete, we will contact you to discuss bed availability and to schedule an intake appointment. Should you have any questions, please feel free to contact us at .

How did you hear about Mending Hearts, Inc.?
(Required)

Applicant Name (Required)

Are you known as something else other than your legal name?

Yes

Also known as? - #1

Also known as? - #2

Upload an image of your Face

Accepted file types: jpg, png. Max. file size: 100 MB.

Street Address (Required)

Address Line 2

City and State (Required)

ZIP Code
(Required)

Email
(Required)

Phone Number
(Required)

Time living in the State of Tennessee? (Required)

Gender of Applicant (Required)

Female

Male

Transgender

Are you a Veteran?(Required)

Yes

Date of Birth (Required)

Social Security Number (Required)

Are you incarcerated? (Required)

Yes

Please enter the name of the facility you are incarcerated at:

Cancel

Step 1 of 8

In this section, you can provide your insurance information. Mending Hearts, Inc. ensures the confidentiality and security of your details, making the process of handling your insurance straightforward and hassle-free.

Do you have insurance?

Yes

Do you have TN Care or Medicaid?

Yes

Subscriber's Name

Insurance Company (Primary)

Insurance ID# (Primary)

Insurance Group# (Primary)

Insurance Company Phone Number (Primary)

Effective Date (Primary)

Do you have Secondary Insurance?

Yes

Cancel

Step 2 of 8

This section asks important questions to determine priority ranking for our services. Specifically, we need to know if you are pregnant or if you are an IV drug user. This information helps us provide the most appropriate care and support.

Are you Pregnant?(Required)

Yes

Are you an IV Drug user? (Required)

Yes

Cancel

Step 3 of 8

In this section, we ask you to identify your substance of choice. As a rehab clinic, Mending Hearts needs to understand what substances you are currently using to tailor our treatment plans effectively and provide the best possible care.

Substance #1 - Drug of Choice(Required)

Substance #1 - How is it used?(Required)

Substance #1 - How often is it used?(Required)

Substance #1 - Age of first use?(Required)

Please enter a number from 10 to 80.

Substance #1 - Date of Last Use
(Required)

Is there a second drug you use?

Yes

Have you ever been a victim of? (select all that apply)(Required)

Domestic Abuse Human Trafficing Sexual Assault Crime None of the above

Cancel

Step 4 of 8

This section inquires about your current and prior treatments. Understanding your previous experiences with rehab allows Mending Hearts, Inc. to tailor our approach and provide the most effective care for your recovery journey.

Are you currently in or have you previously sought treatment?(Required)

Yes

List any additional information regarding treatment you have had or info that you feel we need to know.

Cancel

Step 6 of 8

This section gathers information regarding any legal issues you may be facing. Providing these details helps Mending Hearts, Inc. understand your situation better and ensures we can offer the appropriate support and resources during your treatment. This section inquires about your current and prior treatments.

Are you currently on parole or probation?(Required)

Yes-Parole

Yes-Probation

No, I don't have any legal issues.

Additional comments relative to legal issues?

Cancel

Admission Form

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Terms of Use

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Terms of Use