Pre-Qualification Form

TYFC CARES HTT, before I connect you with a 24 hr. Life Specialist, may I first take down your full name, mobile number and email address?

Not a problem, Do you mind if I put you on a brief hold while I transfer your call?

What is your first name?

What is your last name?

What is your email address?

Do you have a mobile phone that can receive texts?

Do you have an alternative phone number?

What City are you from?

What State are you from?

Are you calling about residential treatment?

Please give me a moment, while I look up our company directory so that I can transfer you to someone that can better help you?

Are you calling for yourself or someone else? [IF not 'Self' THEN] What is your relationship to the patient?

May I ask you some personal questions to determine how you will pay for treatment?

Who is your insurance?

(eg: Discover, Citibank, AMEX, etc None)

Please hold while I lookup the phone numbers and websites of lenders we work with. I'll also email and text you the information as well. You'll be able to apply online or call for instant qualification.

In order to serve you better we will need to know your income bracket? Is it None, Lower, Middle, or Middle-to-Upper?