Pre-Admission Form

The form below has been developed to help us learn more about your psychiatric and/or substance-related need. Filling out this form online can help us streamline the admissions process when you arrive at Seven Hills. However, please know that filling out this form does not obligate you to be admitted neither does it guarantee admission. Complete this form and someone will contact you within 15 minutes by phone.

PERSON COMPLETING THIS FORM
First Name*
Last Name*
Email*
Home Phone*
Work Phone*
Cell Phone*
Date of Birth
Best time to call
Preferred contact phone
May we leave a message?	Yes No
APPLICANT
Name*
Nickname
Address*
Address 2
City*
State*
Zip*
County
Country*
Home Phone*
Work Phone
Cell Phone
Male/Female*
Date of birth*
Race
Marital status*
Education level
Employed*
Legal status*
SERVICES
I am interested in*
EMERGENCY CONTACT INFO
Name*
Relationship to applicant*
Address*
Address 2
City*
State*
Zip*
County
Country*
Home Phone*
Work Phone
Cell Phone
REFERENT (If applicable)
Name
Title
Agency
Relationship to applicant
Address
Address 2
City
State
Zip
County
Country
Home phone
Work Phone
Cell phone
GUARANTOR
Guarantor
That person's name*
Relationship to applicant*
Date of birth
Address
Address 2
City
State
Zip
County
Country
Home Phone*
Work Phone
Cell Phone
FINANCIAL INFO
How do you plan to pay for treatment?
	(If insurance)
Insurance Co.
Group #
ID #
Insurance Phone
	* required fields

* required information

Privacy is paramount at Seven Hills Behavioral Institute. In compliance with federal privacy and confidentiality laws, Seven Hills Behavioral Institute will keep your email address and contact information completely private. We will not share your information with any third party. Your privacy is of critical importance to us. This is our pledge.