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Application for Services
Please fill out the following form to help us understand your needs.
Social Security Number
Insurance Member #
Date of Birth
Have you experienced any of these in the last 30 days
Change in sleep patterns
Change in eating patterns
Change in sex patterns
Have you used any substance within the last 30 days? If yes, please provide the name of the substance
What substances have you used in the past?
Have you ever received inpatient or outpatient rehab services
Have you received or managed your mental health in the past?
Yes, in the past
Never received mental health care in the past
No, not currently managing
I declare that the info I’ve provided is accurate & complete. I understand this is an application for services with financial obligations. I am applying for services and know that I will be notified of all possible payment options to include my insurance company, government assistance, if possible and scholarship funding.
What services ar you in need of?
How did you hear about us?
If angency referral is selected: Enter name below.
Thanks for submitting!
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