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Wellness Programs
Lodging
School Of Massage
Contact Us
Make a Donation
Wellness Programs
Lodging
School Of Massage
Contact Us
Make a Donation
Wellness Programs
Lodging
School Of Massage
Contact Us
Wellness Programs
Lodging
School Of Massage
Contact Us
Donate
Wellness Programs
Lodging
School Of Massage
Contact Us
Make a Donation
Wellness Programs
Lodging
School Of Massage
Contact Us
Make a Donation
Wellness Program
Initial Form
Submission Date
Are you the session participant for this application?
YES
NO
Last Name
First Name
Middle Name
Do you have any other names that you have gone by in the past?
YES
NO
Gender
Male
Female
Date of Birth
Age
Email
Cell Phone Number
Other Phone Number
Occupation
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
How did you hear about Black Hills?
Did your physician refer you to the program?
YES
NO
Have you previously seen or talked to a healthcare provider at BHHEC?
YES
NO
Is there a companion who will be going through the program with you?
YES
NO
Emergency Contact:
Name
Relationship to you:
Parent
Spouse
Employer
Friend
Other
Cell Phone #
Other Phone #
Height
Weight
List ALL problems/diagnoses along with other information required.*
How is your physical condition affecting you?
What is your level of functioning now?
Please list any functions that you have difficulty with.
Have you been hospitalized in the last 6 months? If so, please explain.
Do you have any problems with eating or with your appetite?*
YES
NO
Are you strong enough to get into a high bathtub? (20 inches)
YES
NO
Can you get into and out of bed on your own?
YES
NO
Do you smoke?
YES
NO
Do you drink alcohol?
YES
NO
What health concerns would you like to address? Write a brief description of each concern next to the condition
Diabetes - Type I or type II
Heart Disease/Hypertension
Cancer
Weight Management
Arthritis
Stress Management
Intestinal Disorders:
Pain Management
Other
Do you have any mental or emotional challenges?
YES
NO
Do you have issues with depression?
YES
NO
Do you have issues with anxiety?
YES
NO
You must complete the deposit payment first $500.
This is the link where you can deposit the payment:
Payment Link
Proof Of Payment:
Send
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