Order Number YOUR DETAILS First name: * Last name: * Email Address * Phone: * Describe Current Situation: * Do you have insurance? * Yes No Have you had a Rule 25 Chemical Dependency Evaluation Completed? * Yes No Are you pregnant? * Yes No Are you an IV user? * Yes No Are you planning on bringing any children (must be age 8 or younger) to treatment? * Yes No * Prior to acceptance, a current Rule 25 CD evaluation or update must be completed. If you have a copy of your Rule 25 CD evaluation, it can be attached in the field below, or it may be faxed to Wellcome Manor Admissions Department, (507)218-2243. Copy of Your Rule 25 CD Evaluation: All clients will be scheduled for a telephone screening between the hours of 8:00 AM and 4:30 PM. * Thank you for your interest in Wellcome Manor. An Admissions Representative will contact you the following business day. If everything is correct, press SEND.