Verify insurance

What substances are you currently using?

How frequently do you use it? (Daily, weekly, binge patterns, etc.)

When was your last use?

Have you previously attempted to stop or reduce use?

Have you attended treatment before? If yes, when and where?

Have you ever been diagnosed with a mental health condition?

Yes

No

Are you currently seeing a therapist or psychiatrist?

Yes

No

Have you ever been hospitalized for mental health reasons?

Yes

No

Do you experience symptoms of anxiety, depression, trauma, or mood swings?

Yes

No

Are you seeking private-pay options?

Yes

No

Insurance

Insurance Provider (if applicable)

Policy Number

Primary Policy Holder

Almost there, we just need your contact info