Date of Birth
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Why are you seeking treatment (substance abuse, eating disorder, mental illness)?
If substance abuse, will detox be needed?
Have you been treated before for this illness? If YES, please explain:
Please state services requested and approximate cost:
Do you have medical insurance?
If yes, please provide policy and group ID number:
Can you provide a recommendation from a primary care physician or therapist?
Is there any other information that you wish to provide?