SAMH Pre-Treatment Screening
This form helps us formulate a customized treatment plan for your needs. We will contact you with an appointment date or questions only after you have answered all questions correctly and submitted this.
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Patient Name *
Date of Birth *
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/
DD
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Age *
Social Security Number *
Home Address (include city, state, zip) *
Best Contact Number *
Best Contact Email Address *
Best Time to Contact *
Required
Emergency Contacts
By law, we are required to obtain TWO (2) emergency contact numbers for each of our patients
Emergency Contact 1 Name *
Emergency Contact 1 Home Address *
Emergency Contact 1 Best Contact Number *
Emergency Contact 2 Name *
Emergency Contact 2 Home Address *
Emergency Contact 2 Home Address *
Race *
Gender *
Insurance Company *
Insurance Plan Name *
Group Number *
Policy Holder Name *
Policy Holder Date of Birth *
MM
/
DD
/
YYYY
Policy Holder Social Security Number (if different from patient) *
Policy Holder Address (if different from patient)
Policy Holder Phone Number (if different from patient)
Reason for seeking treatment *
Required
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