Patient Application Form

  • Your Contact Information

  • Emergency Contact Information

  • Doctor Information

  • Questionnaire

  • Client Consent and Release

    I acknowledge that I have received, have read (or have had read to me) and understand the information provided to me by Crossroads Treatment Center regarding the therapy that I am considering. Further I have had all of my questions throughly answered.

    Accordingly, I do hereby seek and consent to taking part in the recovery oriented system of care provided by Crossroads Treatment Center, its contractors, sub-agents and/or employees and I am entered into this treatment without coercion, promise, demand or threat. I have provided Crossroads Treatment Center with a completely thorough and truthful account of my medical history, current and past prescription medication use and current/past recreational drug use.

    behavioral health, counseling, recovery coaching, case management, supportive services, mentoring or any other procedures provided by Crossroads Treatment Center, its contractors, sub-agents and/or employees.

    I understand that no promises have been made to me as to the anticipated results of this treatment, behavioral health, counseling, recovery coaching, case management, supportive services, mentoring or any other procedures provided by The Avante Institute, it’s contractors, sub-agents and/or employees.

    I am aware that I am free to stop the course of treatment at any time but that all fees and costs are non-refundable and that any outstanding fees will be required to be honored and settled with Crossroads Treatment Center.

    My signature below indicates that I understand and agree with all of these statements.
  • Please review the list of guidelines and open it up for questions and concerns

The Crossroads Treatment Center is now the Crossroads Research Initiative, a single source compiling psychedelic research data, offering expert consultations, clinical guidance, case studies and best practices for integrative psychedelic medicine.
close