SAMH Pre-treatment Screening
Patient Name *
Your answer
DOB *
MM
/
DD
/
YYYY
Address *
Your answer
SSI *
Your answer
Age *
Your answer
Gender *
Your answer
Phone *
Your answer
Best time to contact *
Required
Phone Number One *
Your answer
Phone Number Two
Your answer
Is this a working phone number? *
Insurance Company *
Your answer
Insurance member number *
Your answer
Reason for seeking treatment *
Required
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