ADMISSION FORM

This form lets the patient, his or her family member, or a professional referent provide Harmony Foundation with the information we will need to begin the admission process. Completing this form does not obligate you to begin treatment with us.

* is required
PERSON COMPLETING THIS FORM
Home Phone*

Work Phone*

Cell Phone*

Full Name*

Date of Birth

Program of Interest*
APPLICANT
Home phone

Cell phone

Gender*

Date of birth*

Marital status*

Education level

Employed?*
yesno
Name*

Address*

Address 2

City*

State*

Zip*



GUARANTOR
Self guarantor?* yes no
That person's name*

Relationship to applicant*

Date of birth

Phone*

Address

Address 2

City

State

Zip

EMERGENCY CONTACT INFO
Relationship to applicant*

Phone*

State*

Zip*

Name*

Address*

Address 2

City*

REFERENT (If applicable)
Relationship to applicant

Title

Phone

State

Zip

Name

Agency

Address

Address 2

City

FINANCIAL INFO How do you plan to pay for treatment?
If insurance:
Group #

ID #

Insurance Co.

Insurance phone