Contact Facebook Twitter Instagram Phone Office: 800-347-7244On-call: 866- 990-8582 Email contact@thestillwatercentre.com Request More Information / Callback Inbound Client Information Form Insurance Information Request More Information / Callback Name First Last Email PhoneQuestions / Comments Δ Inbound Client Information Form Name Client First Name Client Last Name Client Email Client PhoneNature of AddictionIf the Client is being brought in by a "Co-Sponsor" complete the following:Co-Sponsor Name Co-Sponsor First Name Co-Sponsor Last Name Co-Sponsor Email Co-Sponsor PhoneRelationship to ClientCommentsCurrent State of the ClientClient BackgroundIs Detox Expected? Yes No Please list all drugs that have been taken in the last 6 months:Please list the client's drug of choice:Please list approximate daily consumption of drugs over the last week:MondayTuesdayWednesdayThursdayFridaySaturdaySundayWhen was the last time the client used? Please detail the last 24 hours of use: Δ Insurance Information If the Client has any benefits through work or other means we may be able to supplement care by leveraging benefits. Additional services such as Massage and other services can be leveraged to supplement client care. Please provide coverage information below and attach picture where possible.Name Client First Name Client Last Name Health Care Benefits ProviderPlan NumberIndividual NumberAdd FileAdd File Δ