CHAD Services Intake Form
Please fill out the following information to help us serve you better.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Referred by
*
Drug of Choice/Concern
*
Health Insurance Member Name
*
Health Insurance ID/Policy Number
*
Health Insurance Date of Birth
*
-
Month
-
Day
Year
Date
Health Insurance Group Number (if applicable)
Is this mandated? *
*
Yes
No
Is this for a minor under 18?
*
Yes
No
Parent/Guardian Name
Parent/Guardian Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Submit
Should be Empty: