Name
Email
Phone
Address
Date of Birth
Employment Status
Annual Income
Proof
Allowed file types: png, jpg, pdf. Up to 5MB.
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?
Date:
Applicant Signature:
