Ridge Residential Treatment Application

Name *

First

Last

Email *

Birthdate *

Gender *

Social Security Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Emergency Contact Information

Name *

First

Last

Relationship *

Phone *

Email *

Medical Information

Primary Care Physician *

Physician’s Phone Number

Current Medications *

Allergies *

Medical Condition(s) *

Psychiatric Diagnoses *

Insurance Information

Medical Office Signature

Insurance Provider *

Policy Number *

Group Number *

Policy Holder’s Name *

First

Last

Policy Holder’s Date of Birth *

Policy Holder’s Relationship to Applicant *

Substance Use History

Primary Substance(s) Used *

Duration of Use *

Date of Last Use *

Previous Treatment Attempt(s) *

Probation Office (if applicable)

Consent and Agreements

I hereby consent to participate in the treatment program at Ridge Residential Treatment Center. I understand the nature of the treatment and agree to follow the rules and guidelines of the facility.

Signature *

Clear Signature

Release of Information

I authorize Ridge Residential Treatment Center to obtain and release my medical, psychiatric, and personal information to my insurance provider and other relevant parties for the purpose of treatment and billing.

Signature *

Clear Signature

Financial Agreement

I understand that I am responsible for the costs of treatment not covered by my insurance provider. I agree to arrange payment plans or seek financial aid if necessary.

Signature

Clear Signature

Additional Information

How did you hear about Ridge Residential Treatment Center? *

What are your treatment goals? *

Do you have any specific needs or preference for your treatment? *