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Online Admission Form

Brighton Center for Recovery Secure Online Admission Form

Welcome to Brighton Center for Recovery! You have taken the right step in looking for help with addiction. The next step toward receiving treatment at Brighton Center for Recovery is completing this form. A Customer Service Representative will review your substance abuse history and insurance benefits and call to schedule an admission assessment for you or a loved one within 24 hours.

If you prefer to speak with us, or need assistance in completing this form, please call a Customer Service Representative at 1-877-976-2371. Representatives are available from Monday - Friday, 8am - 11:30pm and weekends from 8am - 6:30pm.

You can also text the word BEST to 9 10 11 to receive an automated call with information about our programs. Please note that the secure form seeks information for each field listed. If you don't have the answer for every question, that's ok too. Just put a question mark (?) in any item where you lack information. The most important thing is to open a line of communication with us. That's where the healing starts! All information provided is kept secure and confidential to be used only by Brighton Center for Recovery.

Your Information

(patient representative / family member / referral agent)
(*) Fields are required.
*First Name:
Middle:
*Last Name:
*Address 1:
Address 2:
*City:
*State/Province:
*Zip Code/Postal Code:
*Country:
*Preferred Contact Phone Number:
Fax:
Email Address:
*Relation to Patient:

Patient Information

*First Name:
Middle:
*Last Name:
*Address 1:
Address 2:
*City:
*State/Province:
*Zip Code/Postal Code:
*Country:
*Preferred Contact Phone Number:
*Social Security Number:
*If no SSN, give reason why:
*Drivers License/State ID:
*License Reason:
Employer:
*DOB: (mm/dd/yyyy)
Gender:
Marital Status:
Ethnic Group:
* 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
Had prior treatment?
Name of Program:
Dates in which treated:
Treatment Experience(s) - Continued
Name of Program:
Dates in which treated:
Name of Program:
Dates in which treated:
Have you ever:
Had thoughts of killing yourself?
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?
Are you currently being treated for any medical problems?
Describe:
Please check any of the following that apply to you - Optional
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 is covered under someone else’s policy?
Primary Insurance Company
Insurance Company: (check one) Blue Care Network
Blue Cross
Connecticut General
Medicare
Medicare Managed Care
Other Insurance
Value Options/Priority Health
Private pay/no insurance
State in which you have insurance:
Insurance Contact Number:
Member Policy Number:
Insurance Group Number:
Plan:
Effective Date:
Secondary Insurance Company
Insurance Company: (check one) Blue Care Network
Blue Cross
Connecticut General
Medicare
Medicare Managed Care
Other Insurance
Value Options/Priority Health
Private pay/no insurance
State in which you have insurance:
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)

Optional

How did you learn about Brighton Center for Recovery?