Admissions Application

* is required

PERSON COMPLETING THIS FORM
First Name: *
Last Name: *
Work Phone: *
Home Phone: *
Cell Phone: *
Date of Birth:
Program of Interest: *
PERSON SEEKING ADMISSION
First Name: *
Last Name: *
Nickname:
Address: *
Address 2:
City: *
State: *
Zip: *
County: *
Country: *
Work Phone: *
Home Phone: *
Cell Phone:
Male/Female: *
Date of Birth: *
Race:
Marital Status: *
Education Level: *
Employeed: *	Yes No
Legal Status: *	US Citizen Non US Citizen
GUARANTOR
Self guarantor: *	Self-gaurantor
Someone else: *	Yes No
That persons name: *
Relationship to applicant: *
Date of Birth: *
Address:
Address 2:
City:
State:
Zip:
County: *
Country: *
Home Phone: *
Work Phone:
Cell Phone:
EMERGENCY CONTACT INFO
	Same as person completing form
Name:
Address: *
Address 2:
City: *
State: *
Zip: *
County: *
Country: *
Home Phone: *
Work Phone: *
Cell Phone:
Referent (If Applicable)
	Same as person completing form
Name:
Title:
Agency:
Relationship to applicant:
Address:
Address 2:
City:
State:
Zip:
County:
Country:
Home Phone:
Work Phone:
Cell Phone:
FINANCIAL INFO
How do you plan to pay for treatment:
(If Insurance)
Insurance Company:
Group #:
ID #:
Insurance Phone: