Full Name *

Date of birth *

Address

Street Address *

City *

State *

Country

Postal Code

Email *

Phone *

Ok to communicate by text? *

Ok to leave a voicemail?

Social Security Number *

Todays Date *

Employer *

How did you hear about us? *

Gender Identity

Insurance Information

Primary Insurance *

Member ID # *

Are you the subscriber *

If not, please provide the policy holder’s name, date of birth, and relationship to you. *

Emergency Contact Information

Name, Phone Number, Relationship to you

Please note: This intake form includes only basic identification and contact information. Because our center provides addiction treatment services, you will receive additional documents during your first appointment that explain your rights to confidentiality, privacy protections, and consent/release-of-information requirements. These documents will be given to you to read carefully when you arrive; you will be asked to review and, if required, sign them before beginning treatment.