APPLICATION FOR ADMISSION

CONTACT INFORMATION

Thank you for taking an interest in Riviera. Please complete the following information as
completely as you can and email the attached pages to our offices:

Address: 6531 Zumirez Drive, Malibu, CA 90265
Phone: 866.478.8799
Email: info@rivierarecovery.com

Once we receive this information, we will conduct a candid appraisal of the appropriateness of the applicant for Riviera. The accuracy of the information given here will help us in effectively understanding the applicant. Keep in mind, that this is a screening application, designed to gather information in an expedient, yet thorough manner. Following admission, we may need your cooperation in requesting additional information. All applications are reviewed within 24-48 hours and appropriateness is determined.

Transportation:
Los Angeles International Airport (LAX) or Bob Hope Airport (BUR) are the most convenient airports to the Riviera campus. For those flying privately, Van Nuys Airport (www.lawa.org) would provide the necessary requirements.

Admission Criteria: At the time of the physical admission to Riviera, staff will do an assessment
to ascertain whether or not the applicant is physically and mentally suitable for admission. Riviera does not provide on-site medical, psychiatric stabilization or detoxification services. Should such services be needed, we have several places that we work closely with that can be utilized to provide such a service. Any such services are extraordinary and will be covered outside of Riviera fees and tuition. We can coordinate admission to such places.

Riviera can accommodate an applicant that has not completed a primary treatment program
and once the person enters our program they must remain abstinent, except for prescribed medications. Riviera is a voluntary program for young adults that have the legal rights to make their own decisions and determinations. If the applicant is recalcitrant, refusing and unwilling to participate in the program at any time during their stay or relapses into drug and alcohol use, Riviera reserves the right to immediately discharge the applicant. At that point, we assume no responsibility for transportation, monitoring of the client or arrangements to another facility.

Forms of payment: We accept wire transfer, checks, cash and most major credit cards (Visa,
MasterCard, American Express, & Discover).

How do I get them there? In some of the cases, our young adults seek us out. However, we understand the nature of young adult addiction and recovery, which is our primary expertise. We have relationships with experts in the field in intervention, primary treatment, transportation and in regards to many other situations. Our admissions counselors can help you devise a plan to benefit your particular situation. Give us a call.

  

CONTACT INFORMATION

Applicant 1

Gender
MaleFemale

  

PARENT/GUARDIAN/FINANCIAL SPONSOR (Primary)

  

Father

  

Mother

  

Family/Living Situation

  

Referral Source

  

Reason For Referral

  

APPLICANT HISTORY AND BACKGROUND

  

Education

  

EMPLOYMENT

Describe any work history and if there are any particular vocational interests:

  

PLACEMENT INFORMATION

  

PREVIOUS INVOLVEMENT WITH PROFESSIONALS

  

  

  

  

Detox Residential Treatment
PHPIOPOP

  

Detox Residential Treatment
PHPIOPOP

  

Detox Residential Treatment
PHPIOPOP

  

Do you have a sponsor?
YesNo

  

  

EMOTIONAL/MENTAL HEALTH INVENTORY

Please check any of the following that apply to the applicant:

Anger
YesNo
Obsessions/Compulsions
YesNo
Violence towards others
YesNo
Stealing, Vandalism, Criminal Activity
YesNo
Self Mutilating Behavior
YesNo
Eating Issues
YesNo
Running Away
YesNo
Isolation
YesNo
Suicidality
YesNo
Substance-related issues
YesNo
Risky Sexual Behavior
YesNo
Other Addictive Patterns
YesNo
Mood Issues
YesNo
Gambling Problems
YesNo

  

Does the applicant exhibit any of the following unusual behaviors?

Delusions
YesNo
Hallucinations
YesNo
Paranoid Thinking
YesNo
Nightmares
YesNo
Tics
YesNo
Stuttering
YesNo
Bedwetting
YesNo
Head Banging
YesNo

  

Describe any mental health diagnosis given by licensed Mental Health Professionals:

  

DRUG AND ALCOHOL USE

To the best of your knowledge, please complete the following use history:

  

Alcohol

Alcohol
YesNo

  

Cigarettes

Cigarettes
YesNo

  

Marijuana

Marijuana
YesNo

  

Hallucinogens (PCP, LSD, Angel Dust, etc.)

Hallucinogens
YesNo

  

Inhalants (gasoline, paint, glue, etc.)

Inhalants
YesNo

  

Stimulants (cocaine, crack, methamphetamine, etc.)

Stimulants
YesNo

  

Opiates (heroin, methadone, etc.)

Opiates
YesNo

  

Depressants (sedatives, barbiturates, etc.)

Depressants
YesNo

  

  

CURRENT SOBRIETY LENGTH

  

OTHER ADDICTIVE PATTERNS

  

LEGAL PROBLEMS

  

FAMILY HISTORY

  

MEDICAL INFORMATION

General Health Condition:
GoodAveragePoor
Please check areas that you have had issues with:
HypertensionHeart problems/diseaseDiabetesLiverBlackouts (last date?)Lung Problems?Chronic pain? (back, neck, from what)ObesitySeizures: Indicate date of last seizureOther

  

MEDICATIONS

Medication 1

  

Medication 2

  

Medication 3

  

Medication 4

  

ADDITIONAL COMMENTS