Embark PCA Intake
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Embark PCA Intake
First & Last Name
 Street Address, City, State, Zip Code:
Phone Number: 
Email:
Birthdate:
Gender:
Do you have Medicaid?
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Medicaid Provider: 
Medicaid Number:
Do you have other insurance? If so, what other insurance do you have?
Are you on Probation?
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Are you interested in Counseling/IOP?
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Are you interested in Recovery Coaching?
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Once you fill out this form, you  will receive an email from Reliatrax to set up a profile. After that profile is complete, intake forms will be sent. 
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