Online Admissions Questionaire

Submitting this easy form before coming for an assessment or admission will save significant time upon your arrival.

Based on the information you provide, we can verify insurance, medical and other details.

Patient's Full Name: *
Patient's phone number: *
Patient's full street address:
City:
State:
Zip Code:
Email: *
Patient's date of birth: *: month/day/year (eg. 09/23/1969)
Person to contact about this admission if other than patient (family, physician):
Person's phone number:
Contact person's email address:
Employer:
Job Title:
Name of the insurance company: *: Insert 'none' if not available
Subscribers name:
Name of the primary insurance policy holder:
Patient's policy or subscriber ID: *: Insert 'none' if not available
Insurance policyholders date of birth (if known):: month/day/year (eg. 09/23/1969)
Group number:
Insurance provider's customer service phone number:
Substance(s) being used:: Alcohol
Cocaine
Crack
Heroin
Oxycontin
Pills
Meth
Marijuana
Not sure
Other substances (explain). Also please tell us amounts or level of usage.
Comments
How did you hear about us? *

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