Contact

Facebook
Twitter
Instagram
Phone

Office: 800-347-7244
On-call: 866- 990-8582
Email

contact@thestillwatercentre.com

Request More Information / Callback

Inbound Client Information Form

Insurance Information

Request More Information / Callback

Inbound Client Information Form

Name
Client First Name Client Last Name
Client Email
Client Phone
Nature of Addiction
If 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 Phone
Relationship to Client
Comments
Current State of the Client
Client Background
Is 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:
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
When was the last time the client used?
Please detail the last 24 hours of use:

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 Provider
Plan Number
Individual Number
Add File
Add File