Intake Form

1

Who Are You Seeking Treatment For?

Myself

A Loved One

2

What Are You Currently Struggling With?

Alcohol

Substance Abuse

Mental Health

Other

3

What Is Your Loved One Currently Struggling With?

Alcohol

Substance Abuse

Mental Health

Other

4

Please Indicate The Type Of Health Coverage You Have

PPO

HMO

Medicare/Medicaid/State insurance

5

Please Indicate The Type Of Health Coverage Your Loved One Has

PPO

HMO

Medicare/Medicaid/State insurance

8

Please Specify The Insurance Provider* This field is required.

9

What Is Your Insurance Member ID/Number?* This field is required.

10

What Is Your Full Name?* This field is required.

First Name

Last Name

11

What Is Your Loved One's Full Name?* This field is required.

First Name

Last Name

12

What Is Your Email Address?* This field is required.

13

What Is Your Zip Code?* This field is required.

14

What Is Your Date Of Birth?* This field is required.

Date

15

What Is Your Loved One's Date Of Birth?* This field is required.

Date

16

What Is Your Phone Number?* This field is required.

Please enter a valid phone number.