Registration form

Patient/Contact Information

(*) Fields are required

*First Name:

Middle Name:

*Last Name:

Address:

*City:

*State:

*Zip Code:

*Phone Number:

*Email Address:

*Relationship to Patient:

Additional Information

*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 Eastside Outpatient Center?

 clear form

Google Maps

Contact us today!

445 E. Sherman Blvd, 49444

231.739.4395

Hours of Operation