[Skip to Content]

Intake Demographic Information

  • Information Needed for Admission and Enrollment

  • Date Format: MM slash DD slash YYYY
  • Your Contact Information:

    Include all Contact Numbers
  • Emergency Contact Information:

    (Non Parent/Guardian) Other than Listed Above
  • Insurance Information:

  • Date Format: MM slash DD slash YYYY
  • Psychiatrist:

  • Therapist:

  • Primary MD:

  • Any other Release needed for a provider / Probation, Education Consultant etc…

  • Names of Hospitals / Residential Programs Patient has Attended Most Recently: