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Registration Form


Patient/Contact Information
(*) Fields are required.
* First Name:
Middle Name:
* Last Name:
Address:
* City:
* State:
* Zip Code:
* Phone Number:
Email Address:
* Relation to Patient:

Identification
Social Security Number:
If no SSN, give reason why:
Drivers License/State ID:
No Driver's License/State ID Number, provide reason why:
 
Additional Information
* DOB: (mm/dd/yyyy)
* Gender:
Marital Status:
Ethnic Group:
 
Insurance Information
Do you have coverage?
Are you covered under someone else's policy?
Insurance Company: Blue Care Network
Blue Cross
Connecticut General
Medicare
Medicare Managed Care
Value Options/Priority Health
Private pay/no insurance
Other Insurance

State in which you have insurance:
Insurance Contact Number:
Member Policy Number:
Insurance Group Number:
Insurance Plan:
Effective Date:

If your insurance is in another name, please provide the information below:
Insured Name:
Relation to Patient:
Date of Birth: (mm/dd/yyyy)
Still Employed?
Termination Date: (mm/dd/yyyy)

Addictions
* First Substance of Choice:
How long have you used this substance?
How often do you use?
Date of last use:
 
Second Substance of Choice:
How long have you used this substance?
How often Do You Use?
Date of Last Use:
 
Third Substance of Choice:
How long have you used this substance?
How often do you Use?
Date of Last Use:
 
Previous Treatment Experience
Please include inpatient and outpatient treatments
Have you had prior treatment?
1. Name of Program:
Date of treatment:
 
2. Name of Program:
Date of treatment:
Additional Questions
Have you ever:
Had thoughts of killing yourself?
If so when?
Attempted suicide?
If so when?
If you answered yes to any of the above, were you under the influence at the time?
If you were under the influence, which substance?
Are you currently being treated for any medical problems?
Describe problem:

Optional information
How did you hear about HTC/Harbortown Treatment Center?