Rayville Recovery Admissions Form

Confidential Contact Form

First Name Last Name Phone Number Email Address How were you referred to Rayville Recovery?

Client Information

Please tell us about the prospective client

Client First Name Client Last Name Client Date of Birth

Street Address Address Line 2 City State Postal/ Zip Code Country Gender Identification What substances are currently being misused by the client?

Has the person seeking treatment been to residential treatment in the past 30 days? Yes No Not sure

If so, where? What type of treatment are they seeking?

What type of insurance will the person seeking treatment be using? Louisiana Medicaid Commercial Insurance Private Pay No Insurance

If you have insurance, who is your provider?

Additional Background on Client

Has the person seeking treatment been convicted of any sexual or violent offenses? Does the person seeking treatment have any mental health or medical diagnoses? Please list any currently prescribed medication