Admissions Form |
| * Name of person filling out this form: |
* Relationship to patient |
| |
|
| * E-mail address: |
| | Fields marked with an * astrisk are required fields |
|
|
|
| Is the patient ready to come to treatment willingly? |
If no, would you like us to recommend interventionists that may be able help? |
|
|
|
* Is this an intervention? |
If yes, are you working with an interventionist? |
|
|
| If yes, name of interventionist: |
|
| * How did you learn about Father Martin's Ashley? |
|
|
|
|
| Patient Information | |
| * Name of patient: |
Marital status: |
| |
|
| * Patient age: |
| |
|
|
| I am having a problem with: |
|
|
|
| Have you had prior treatment for alcohol or other drugs? |
If yes, please specify where: |
|
|
| Do you have other medical or psychiatric problems? |
If yes, please specify: |
|
If other, please specify:
|
| Are you taking prescribed medications? |
If yes, please specify: |
|
|
| Are you currently under the care of? |
If yes, please specify name: |
|
|
| Please indicate method of payment: |
Who will be the guarantor of the account? |
*Cash amounts over $10,000 must be reported to the IRS |
|
If you would like Ashley to verify your insurance plan benefits,
please provide your medical / mental health insurance information below. All
information is required. On occasion, more information is required to verify
insurance benefits and eligibility.
All information below is required in order for Ashley to verify insurance plan benefits
|
| Insurance company name: |
|
| Insurance company phone number: |
|
| Subscriber name: |
|
|
Subscriber date of birth: |
|
|
|
Patient date of birth: |
|
|
| Relationship of subscriber to patient: |
|
| Member ID number: |
|
| Name of subscriber employer: |
|
| |
|