Pre-Qualification Web Form

Are calling on behalf of yourself or a company?

What is the name of the Company you work for?

What is your Job Title?

What is your first name?

What is your last name?

Do you have a mobile phone that can receive texts?

Do you have an alternative phone number?

What is your email address?

What City are you from?

What State are you from?

Do you happen to remember what search words you googled to find us?

How did you find out about us?

Did you happen to jot down the promo code by chance?

What was the name?

Are you looking for residential treatment?

May I ask how treatment will be paid for?

Do you have State, Federal or Military Insurance?

What is the name of your insurance provider?

Our Life Specialist will be able to give you more details on pricing and method of payment.

In order to serve you better we will need to know your income bracket.

Would you like to complete a brief loan application?

Can you tell us what will be your alternate source of payment?

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

What is the Patient's Name?

What is the Patient's age?

What is the Patient's gender?

How soon are you wanting to admit (or be admitted)?

Can you tell us in a few words what is the diagnosis or presenting problem? You will have the opportunity to explain in detail to the Life Specialist.

We will need the information on your card if you'd like us to verify your insurance benefits and out-of-network eligibility.