706-419-3883

Guest Questionnaire

Thank you for speaking with our Guest Services team. Please complete this questionnaire so our medical and program staff can prepare for your stay. Answer each item as fully as possible, and leave an item blank if it does not apply. Your answers are kept confidential.

Guest Application – Step 2

Your Information

Please use the same email you entered on your initial application.

Personal, Household, and Emergency Information

Companion Information

Will you be coming with a companion during your stay?

Program and Admission Information

Length of Stay Requested
Room Preference

Current Concerns and Program Goals

Past Medical and Surgical History

Have you been to the Emergency Room or hospital within the past three months?

Medications, Supplements, and Food Allergies

Are you currently taking any prescription medications?
Are you currently taking any over-the-counter medications?
Are you currently taking vitamins, herbs, or nutritional supplements?
Do you have any food allergies or intolerances?

Functional Status and Care Needs

Do you currently have difficulty with any of the following?
Do you use any assistive device?
Will you require assistance from a caregiver for safety, mobility, personal care, or daily needs during your stay?

Mental and Emotional Health

How would you rate your current mental and emotional well-being on a scale from 0 to 10?
0 = very poor, 10 = excellent
Have you ever been diagnosed with a mental health condition?
Are you currently receiving therapy or psychiatric care?
Is there a family history of mental health conditions?
Have you ever attempted suicide?
Do you currently have suicidal thoughts?
Do you currently have thoughts of harming yourself or someone else?

Please note: If your mental health history is significant, recent records from your treating provider may be requested.

Substance and Caffeine Use

In the past year, have you used any of the following?

Nicotine (cigarettes, cigars, or vaping)

Nicotine (cigarettes, cigars, or vaping) – used in the past year?
Do you want to reduce or stop using it?

Alcohol

Alcohol – used in the past year?
Do you want to reduce or stop using it?

Recreational or illicit drugs

Recreational or illicit drugs – used in the past year?
Do you want to reduce or stop using it?

Cannabis or cannabis-derived products

Cannabis or cannabis-derived products – used in the past year?
Do you want to reduce or stop using it?

Narcotic pain medication

Narcotic pain medication – used in the past year?
Do you want to reduce or stop using it?
If you currently use narcotic pain medication, do you understand that our medical staff may not refill these prescriptions during your stay?
This question acknowledges the program policy; it does not advise stopping medication without guidance from the prescribing clinician.

Caffeine

Caffeine – used in the past year?

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