(If you are inquiring for someone else, please still enter your name here. You'll enter the patient's name towards the bottom of this form.)
(If you are inquiring for someone else, please still enter your name here. You'll enter the patient's name towards the bottom of this form.)
(Please enter your email address here, so our Admissions Coordinator can contact you about next steps.)
(Please enter your phone number here, so our Admissions Coordinator can contact you about next steps.)
(The organization you are affiliated with)
(Your role at that organization)
(The person who may be receiving services at Core Recovery)
(The person who may be receiving services at Core Recovery.)
(The person who may be receiving services at Core Recovery)
(Please include any prefixes, etc.)
Note: You may be the Primary Policyholder, or the Primary Policyholder may be a parent, spouse, etc.
Note: Enter the date of birth of the Primary Policyholder of the insurance policy. If you are the Primary, enter your birthdate.
Please type the date in this format: MM-DD-YYYY
I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.