PATIENT INFORMATION

Full Name *

Gender *

Female

Male

Patient Age *

Date of birth *

State *

Postal code *

Phone *

Email *

Addicition *

Alcohol
Cocaine
Hallucinogens
Heroin
Marijuana
Meth
Methamphetamine
Opioid
Prescription medicine
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Have you ever visited our facility? *

Yes
No
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Have you ever been an inpatient at any facility? (Yes/No) *

Where and how long ago were you an inpatient?

If patient is under 18 years of age, enter guardian information below.

Guardian Name

Guardian Date of Birth

Guardian Phone

EMERGENCY CONTACT INFORMATION

Emergency Contact

Relationship to Patient

Emergency Contact Phone Number

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