Indivdual counseling, Family Counseling and Marital counseling

Thank you for your interest in Rehab After Work.

Please fill out the information below and an intake worker will call you within 48 hours to offer you an appointment time. If you already have a counselor and need to submit your information for billing please list the counselor's name in the additional questions area.

Information Request Form

Last Name:
First Name:
Home Address:
Home Phone #:
Work or Cell Phone #:
Employer:
Email:
Date of Birth:

Social Security #:
Type of Insurance: (ie. Personal Choice)
Insurance ID #:
Who is the subscriber on your insurance policy?:
Subscriber's date of birth:
"Provider" phone number on back of insurance card:
Emergency Contact:
Emergency Contact #:
Which Location:
Preferred Appointment Time:	Day Evening
Faith: (optional)
Briefly answer the following questions: What substance are you using? Daily amount used? When did you last use?
Who referred you to us?:
Any questions you need us to answer?:

Your personal level of care will be determined by an initial evaluation. If you have any questions, you may discuss them with the intake staff who will contact you for scheduling. We will make every effort to schedule you at the location you have selected above.