Treatment Application
Date
*
-
Month
-
Day
Year
Date
Name
*
First Name
Last Name
Gender
Date of Birth
*
-
Month
-
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Social Security Number
*
Your Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
Does anyone need to know your applying for treatment? (Check All that Apply)
Probation
DOC
Employer
MH
DSHS
CPS
Family
Is this court ordered?
Yes
No
If Yes, By Whom? (Documentation?)
Have you completed an Assessment or Evaluation before?
Yes
No
If Yes , Where?
Emergency Contact
First Name
Last Name
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
What substances are you currently using?
Date of Last Use
-
Month
-
Day
Year
Date
What medications are you prescribed and taking?
American with Disabilities (ADA) accommodations needed?
Yes
No
If Yes please describe
Type of Payment
Cash pay
Private Insurance
Medicaid
Other
Employment Status
Fulltime
Part Time
Shift Work
Retired
Disabled
Student
Other
Employer
Insurance Info
Insurance Guarantor Name
First Name
Last Name
Insurance Guarantor Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Insurance Guarantor Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Guarantor Relationship to you
Other information you would like us to have at this time ....
State Medical Insurance
Yes
No
If Yes who is the Provider
CHPW
Amerigroup
Molina
Coordinated Care
Other
Submit
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