Admissions

Prescreening Form

"*" indicates required fields

Company

This field is for validation purposes and should be left unchanged.

Contact Information

Name*

Email*

Phone

Are you reaching out for yourself or on behalf of a loved one?*

Self

Someone else

If on behalf of someone, please provide client’s:

Name

First Last

Untitled

Intake Information

What is the reason for contacting our Facility today?*

What Program(s) are you interested in?*

Please tell us about your current and previous substance use

Are you having any thoughts of harming yourself or others?*

Yes

No

Are you currently pregnant, or do you think you might be?*

Yes

No

Have you given birth in the last 28 days?*

Yes

No

Were you recently released from an institution (such as jail or rehab)?*

Yes

No

If yes, from where and when?

Are you currently in mental health or substance abuse treatment?*

Yes

No

Have you had treatment in the past?*

Yes

No

If yes, from where and when?

Are you currently enrolled in pain management or were you enrolled in the past 30 days? (Note: if you were enrolled in pain management, our doctor may request a discharge letter from your pain management provider)*

Yes

No

Do you have insurance? If not, are you able to self-pay?*

Self-pay

Insurance

If you require financial assistance, please reach out to our Admissions team, as we may have alternative options available.

Please do not use any substances within 12 hours of admission. You must bring a photo ID and insurance card in order to be admitted. If you take prescription medication, please bring copies of your current prescriptions.

732-234-0058

Contact Information

If on behalf of someone, please provide client’s:

Intake Information

732-234-0058