After Hours Form - Summit Hill Wellness

Inquiring for *

Me
A Friend / Loved-one

Friend or Loved-One's Name ("Patient") *

First

Last

Your Name ("Patient") *

First

Last

Your Name *

First

Last

Reason for Treatment *

Alcohol
Substance
Gambling
Other

Other Reason for Treatment

During the past 12 months:

Have there been periods of restlessness, irritability or anxiousness when trying to stop/cut down? *

Yes
No

Has there been an attempt to hide or minimize behaviors from family or friends? *

Yes
No

Have financial difficulties resulted from the identified behaviors for which you are seeking treatment? *

Yes
No

Which statement best represents the situation currently *

Health Insurance Coverage *

Insurance Provider

Member ID *

Birth Date

What Program Are You Interested In? *

Learn more about Programs. When we contact you we will help place you in the best program for you.

Patient's Treatment History

None
Outpatient Therapy
Prior IOP or Outpatient Program
Prior Inpatient / Residential treatment

Prior Treatment Details (if any)

Your Phone Number

Can we text you at this number?

Yes
No

Your Email Address

Your Address

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about Summit Hill Wellness?

How did you find us?

Which Treatment Program?

If you were referred by another treatment program, we'd like to say thanks.

Questions or Comments

To ensure program fitness please read and acknowledge the items below *

Summit Hill does not prescribe methadone or suboxone. However these medications will not necessarily prevent you from participating in the program.
Summit Hill programs are typically 4-6 weeks in length, with a minimum of 3 weeks and a maximum of 12 weeks.

* Required Field

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