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                   SUMMER SKY TREATMENT CENTER

Pre-Admission

1-888-857-8857

Texas Drug and Alcohol Treatment Center, Summer Sky 



Admission Form

If you or someone you know is interested in treatment, please fill out the Admission Form below and an admissions specialist will get back to you Immediately . You may follow up on your submission by calling 888-857-8857. If you have any questions while filling out this form please don’t hesitate to call.

PERSON COMPLETING THIS FORM:

Full Name:
Email:
Home Phone:
Work Phone:
Cell Phone:
Date of Birth:
 Program Interested In:

Detox Now
Residential Inpatient Adult
Intensive Outpatient Adult

Best Time to Call:
When Would You Like to Be Admitted:

Applicant:

Full Name:
Nickname:
Address:
City:
Zip:
State:
County:
Country:
Home Phone:
Cell Phone:
Work Phone:
Male/Female:
Date of birth:
Marital status:
Highest Leve of Education:
Employed:
Legal status:

EMERGENCY CONTACT INFO:

Name:
Relationship to applicant:
Address:
City:
State:
Zip:
County:
Country:
Home phone:
Work Phone:
Cell Phone:

REFERENT (If applicable):

Full Name:
Title:
Agency:
Relationship to applicant:
Email:
Address:
City:
State:
Zip:
County:
Country:
Home phone:
Cell Phone:
Work Phone:

Self Guarantor:

Guarantor:
If Someone Else Please Fill Out This Section, If Self Please Skip to
Financial Info:
Relationship to applicant:
That Person's Full Name:
Date of Birth:
Address:
City:
State:
Zip:
County:
Country:
Home phone:
Work Phone:
Cell Phone:

FINANCIAL INFO:

How do you plan to pay for treatment?:

If Paying With Insurance Please Fill This Section Out, Skip if Private Pay:

Insurance Company:
Group Number:
ID Number:
Insurance Phone Number:
Comments:
Security Code: *  

Pre-Admission