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Admission Inquiry - RESIDENTIAL

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 * required

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

Initials

Today's Date

Are you currently pregnant? *

No

Yes

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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