MBH: Online Residency Application
Please fill out the below application if you are a male (or identify as male) and are interested in treatment at Mockingbird Hill. You will receive a phone call from our Assessment Technician to complete a screen within 24 hours or the next business day, if applying over the weekend. For further assistance please call our front desk at (765)641-8231
Email
*
example@example.com
Legal Name
*
First Name
Last Name
Date of Birth
*
Address Line 1 (May not be a facility address, but somewhere you can currently receive mail)
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Address 2
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Applicant's email address
*
example@example.com
Applicant Phone (if you do not have a phone, please provide phone number of "Next of Kin")
*
Please enter a valid phone number.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone
Please enter a valid phone number.
Referral Source Name
First Name
Last Name
Referral Source Phone Number
Please enter a valid phone number.
Referral Source Email
example@example.com
Date of last use
*
-
Month
-
Day
Year
Date Picker Icon
Substance(s) used most recently
*
Alcohol
Benzodiazepines (Xanax, Klonopin)
Cocaine
Ecstasy
Fentanyl
Heroin
K2
Marijuana
Methamphetamine
Opiates
Spice
Submit
Should be Empty: