Intake form

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Step 1 of 5

First, please tell us a little about yourself.
This information will be kept confidential and helps us ensure were able to provide you with care.
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Verification of Benefits


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Include the following:

  • Client Name
  • DOB
  • Client Address
  • Insurance Name
  • ID # 
  • Insurance Phone Number
  • Subscriber Name and Relationship
  • Referred By (Treatment Center)
  • Copy of the Insurance Card if available