Diamond Detox Initial Application

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For more info about Diamond Detox please visit diamonddtx.com

Email *

For assistance Call-385-988-5332

Patient Name *

Patient Date of Birth *

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Phone Number *

SMS Text Opt In/Out *

By checking this box, I agree to receive TEXT messages about services from Diamond Detox at the phone number provided above. The SMS frequency may vary. Data rates may apply. Text HELP to *** for assistance. Reply STOP to opt out of receiving SMS messages

Opt Out - Should You choose to opt out our team will be unable to communicate with you by text message.

Required

Reason you are seeking treatment *

Are you seeking Inpatient or outpatient treatment? *

Detox

Intensive Outpatient

Ambulatory(Outpatient Detox)

Other:

Required

Please list current Drugs & or alcohol use, including amount & frequency? *

If you have insurance please provide; Insurance Company, Policy holder name, phone #, address & member ID #. *

Send me a copy of my responses.

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