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Admission Inquiry - OUTPATIENT

Please fill out the following form.

Our Intake Coordinator will contact you shortly to set up a phone screening.

First Name

Last Name

Maiden Name

Email Address

Insurance Name

Date of Birth

Phone (no dashes)

Insurance Number

Please select your housing situation at the time of this application

If you answered "other", please explain:

Do you inject non-prescription drugs using a needle/syringe?

No

Yes

Are you currently pregnant?

No

Yes

Initials

Today's Date

Upload File

Upload supported file (Max 15MB)

I declare that the info I’ve provided is accurate & complete

Our Intake Coordinator will reach out to you shortly!

NEED HELP?

90 McCarty Avenue

Albany, NY 12202

ph: 518.465.5470

ADDICTIONS CARE CENTER OF ALBANY

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