Member Application

If you are in crisis and feel unsafe, do not continue. Dial 911 immediately and seek help. If you were referred by another organization, you have the right to receive treatment from any provider that you choose.

* Indicates a required field

Your Contact Information

* First Name
Middle
* Last Name
Legal Name (if different)
* Preferred Name
Home Phone (-
Mobile Phone (-
* Best Phone
* Can we leave voicemail on this phone
* Best time to call
* Time zone
* Email
* Can we send private email
* What is the best way to communicate
* What time of the day are
you available for group sessions

Please list an emergency contact
 
* Emergency Contact Name:
* Emergency Contact Phone: (-

More Information About You

* Gender
* Birthdate / /
* Marital Status
* Race
* Religious Preference
* Languages Spoken
* Occupation
* Employer
* Physical Address
* Mailing Address
* Shipping Address
* Social Security Number
* Who referred you
* Can we contact the referrer

Technology

* What do you use a computer for?
* Rate your computer skills on a scale
of 1 to 5 with 5 being the highest
* If your computer skills are low, who
will help you access our online programs
and print your homework assignments?
* You will need to be in a private room
with high speed internet when you
attend your video conference sessions.
Describe where that room will be.

If you are filling out this application in the place you will attend
your video conference sessions, please test your internet speed and complete the fields below.
* Download Speed (Mbps)
* Upload Speed (Mbps)
 
Speedtest.net Mini requires at least version 8 of Flash. Please update your client.

Your Payment Information

* Method of Payment
* Person Responsible for Payment
* Person Responsible Relationship to Member
Insurance Company


NOTE: we CANNOT accept Medicare or Medicaid
Name of Primary Policy Holder
Primary SSN
Primary Date of Birth  /  / 
Insurance ID #
Insurance Group #
Insurance Phone #

Consent and Signature

Comments or Special Instructions

Please read the following paragraph
carefully before submitting your application.

I hereby give my consent for representatives of Recovery Help or contracted 3rd party administrators to contact me, my emergency contact, referring individuals and potential payers for the purposes of determining my eligibility for Recovery Help treatment services. Admission is at the sole discretion of Recovery Help.

I understand that Recovery Help has no obligation to store the information I provide beyond the period of time required to determine appropriateness and may dispose of the information at any time thereafter.

By typing my name below and submitting this form, I agree that this signature is my legal signature just as if I signed on a piece of paper and sent to you.

* Type full name as Electronic Signature
(If under age) Guardian must also
type full name as Electronic Signature
If guardian signed, what is your
relationship to applicant?




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Please only click the "Submit Application" button once to prevent duplication.