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Diamond Detox Initial Application
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Email
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Patient Name
*
First
Last
Date of Birth
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MM slash DD slash YYYY
Phone
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SMS Text Opt In/Out
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By checking this box, I agree to receive TEXT messages about services from Diamond Detox at the phone number provided above. The SMS frequency may vary. Data rates may apply. Text HELP to *** for assistance. Reply STOP to opt out of receiving SMS messages
Opt Out – Should You choose to opt out our team will be unable to communicate with you by text message.
Reason you are seeking treatment
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Are you seeking Inpatient or outpatient treatment?
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Detox
Intensive Outpatient
Ambulatory (Outpatient Detox)
Other
Please list current Drugs & or alcohol use, including amount & frequency?
*
Do you have insurance?
*
Yes
No
Insurance Information
Insurance Company
*
Policy Holder Name
*
First
Member ID #
*
Phone Number
*
Address
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Start Your Recovery Today
Get the support you need with safe, medically supervised drug and alcohol detox. Our team is here 24/7 to help you take the first step.
Call (385) 988-5332
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