Admissions Form |
| * Name of person filling out this form: |
* Relationship to patient |
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| * E-mail Address: |
| | Fields marked with an * astrisk are required fields |
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| * Is this an intervention? |
If yes, are you working with an interventionist? |
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| If yes, name of interventionist: |
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| * How did you learn about Father Martin's Ashley? |
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| Patient Information | |
| * Name of patient: |
Marital Status: |
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| * Patient Date of Birth: |
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| I am having a problem with: |
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| Have you had prior treatment for alcohol or other drugs? |
If yes, please specify where: |
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| Do you have other medical or psychiatric problems? |
If yes, please specify: |
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If other, please specify:
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| Are you taking prescribed medications? |
If yes, please specify: |
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| Are you currently under the care of? |
If yes, please specify name: |
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| Please indicate method of payment: |
Who will be the guarantor of the account? |
*Cash amounts over $10,000 must be reported to the IRS |
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| If you want Ashley to attempt to access your insurance benefits for treatment costs, please provide your medical/mental health insurance information below: |
| Insurance Company Name: |
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| Insurance Company Phone Number: |
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| Subscriber Name: |
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| Relationship of subscriber to patient: |
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| Member ID Number: |
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| Name of subscriber employer: |
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