Admissions to Program

NOTE: ALL INQUIRIES AND INFORMATION ARE PROTECTED BY HIPAA CONFIDENTIALITY LAWS

Marital Status:
Sex:
Living Arrangments:

Insurance:
Insurance Plan:
Membership ID:
Name of Policy Holder:
Company plan provided by:
Policy Holders DOB:
Policy Holder's Address:
Referral Required (From Primary Care Physician):	Fax Referrals to: 301-698-5671

Employer:		Occupation:
		Years:

Emergency Contact:		Relationship:
		Phone:

Employer Address:
City:

You will be contacted at the designated contact number today to make your first appointment.
Best time for us to reach you by phone is:

Thank you for contact Allied Counseling Group. We look forward to working with you!