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Brighton Hospital Online Admission Form

The first step toward treatment at Brighton Hospital is completing this form. A Customer Service Representative will review your use history and insurance benefits and call to schedule an admission assessment within 24 hours.

If you cannot complete this form, or need assistance in completing this form, please call a Customer Service Representative at 1-877-976-2371 to provide the necessary information. Representatives are available from 8 a.m. – 11:30 p.m. Monday – Friday; 8 a.m. – 6:30 p.m. weekends.

Please note that we would like to receive all fields filled-in but the "*" fields are required. The information provided will be used only by Brighton Hospital. All information will be kept secure and confidential.

Your Information (patient representative / family member / referral agent)
(*) Fields are required.
*First Name:
Middle:
*Last Name:
*Address 1:
Address 2:
*City:
*State:
*Zip Code:
*Home Phone:
Work Phone:
*Cell Phone:
Fax:
*Email Address:
*Relation to Patient:
Patient Information
*First Name:
Middle:
*Last Name:
*Address 1:
Address 2:
*City:
*State:
*Zip Code:
*Home Phone:
Work Phone:
Cell Phone:
Email - Address:
Social Security Number:
Employer:
Primary Care Physician:
*DOB: (mm/dd/yyyy)
Gender:
Marital Status:
* Insurance Information
 
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:
Treatment Experience(s) – please include inpatient as well as outpatient treatments
Name of Program:
Dates in which treated:
Did you complete treatment?
Was your treatment a 12-Step Program?
Treatment Experience(s) - Continued
Name of Program:
Dates in which treated:
Did you complete treatment?
Was your treatment a 12-Step Program?
Name of Program:
Dates in which treated:
Did you complete treatment?
Was your treatment a 12-Step Program?
Have you ever:
Thought of suicide?
If so when?
Planned a suicide attempt?
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?
In the past year, what is the longest time you have been substance free?
When you have stopped drinking or using on your own, please check the symptoms that you experienced?
Seizures Tremors
Shakes Chills
Nausea Vomiting
Headaches Other
If other ?
Are you currently being treated for physical pain?
Describe:
Are you currently being treated for any medical problems?
Describe:
Are you taking any prescribed medications?
If yes please give the name, dose, and how often you take
them:
Please check any of the following that apply to you:
Do you smoke?
Are you having family problems?
Do you have any legal problems?
Recent or impending loss(es)?
Do you become violent when you use?
Do you have financial problems?
Insurance Information
Does the patient have insurance coverage or covered under someone else’s policy?
Primary Insurance Company
Insurance Company:
Insurance Contact Number:
Member Policy Number:
Insurance Group Number:
Plan:
Effective Date:
Secondary Insurance Company
Insurance Company:
Insurance Contact  Number:
Member Policy Number:
Insurance Group Number:
Plan:
Effective Date:
Insured Party
Insured Name:
Relation to Patient:
Date of Birth: (mm/dd/yyyy)
Still Employed:   Length :
Termination Date: (mm/dd/yyyy)
  
 

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About Brighton Hospital: Brighton Hospital History -  Affiliations -  Awards and Certifications -  Licensure and Accreditation -  Privacy Policy -  Addiction Treatment Medical Staff -  Addiction Treatment Administrative Staff -  Drug Rehab and Alcohol Rehab Patient Testimonials -  Addiction Recovery Patient Videos -  Speakers Bureau -  Press Room -  Drug and Alcohol Addiction featured on Montel -  Outpatient Medical Clinic

Alcohol and Drug Treatment Programs: Types of Treatment Programs -  12 Step Programs and Support Groups -  30 Day Addiction Recovery Program -  Activity Therapy Program - Family Rehab & Sobriety Programs -  Adolescent Drug Treatment -  Addiction Recovery Programs -  Clergy Recovery Programs -  Drug and Alcohol Detoxification (Detox) Program -  Domiciliary Partial Hospitalization Program - Dual Diagnosis Treatment Program -  Henderson Halfway House for Men -  Holistic Healing -  Outpatient Drug and Alcohol Treatment Program -  Michigan Health Professionals Recovery Program -  Alcohol and Drug Rehabilitation Program -  Women's Halfway House -  Rehabilitation Counseling for Family and Friends -  Chemical Dependency Discussion -  Family Retreat Weekend -  Sobriety Events -  Michigan Driver’s License Restoration Assessment Programs -  Opiate (Heroin) Treatment Program -  Insurance and Treatment Cost -  Frequently Asked Questions About Addiction Treatment

Admission and Intervention: Substance Abuse Intervention Checklist -  Chemical Dependency Assessment

Support Brighton Hospital: Donate Online -  501(c)3 Form -  Hospital Donations -  Tree of Hope -  Projects Needing Donations -  Volunteer Opportunities -  Ways to Give -  Fundraising Events -  Brighton Events -  Determine Your Donation -  Contact Donations -  FAQs about Donating to Brighton - Thank You for Your Donations

Alcohol and Drug Rehabilitation Careers: Rehabilitation Clinic Job Postings -  Employment Application -  Apply for a Career at Brighton -  Residential Aide for the Women’s Half-Way House -  Staff Nurse -  Substance Abuse Counselor - Master Level -  Outpatient Substance Abuse Counselor - 

Types of Treatment at our Center: Alcohol and Drug Treatment Clinic -  Cocaine Rehab Program -  Crack Treatment Clinic -  Heroin Treatment Facility -  Marijuana Rehab Center -  Meth Treatment Program - Facilities

Brighton Hospital is an alcohol and drug treatment center helping patients worldwide including: Alabama (AL), Alaska (AK), Arizona (AZ), Arkansas (AR), California (CA), Colorado (CO), Connecticut (CT), Delaware (DE), Florida (FL), Georgia (GA), Hawaii (HI), Idaho (ID), Illinois (IL), Indiana (IN), Iowa (IA), Kansas (KS), Kentucky (KY), Louisiana (LA), Maine (ME), Maryland (MD), Massachusetts (MA), Michigan (MI), Minnesota (MN), Mississippi (MS), Missouri (MO), Montana (MT), Nebraska (NE), Nevada (NV), New Hampshire (NH), New Jersey (NJ), New Mexico (NM), New York (NY), North Carolina (NC), North Dakota (ND), Ohio (OH), Oklahoma (OK), Oregon (OR), Pennsylvania (PA), Rhode Island (RI), South Carolina (SC), South Dakota (SD), Tennessee (TN), Texas (TX), Utah (UT), Vermont (VT), Virginia (VA), Washington (WA), West Virginia (WV), Wisconsin (WI), Wyoming (WY), Ontario and Quebec Canada.

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