Admission Intake FormPlease fill out the information below to begin your adolescent’s admit process for The Maples. Adolescent’s Name Adolescent's Date of Birth Main Reason Seeking this Level of Care Client’s Allergies Parent/Legal Guardian’s Name Custody Status Parent/Legal Guardian’s Email Parent/Legal Guardian’s Phone Number Address Name of Insurance A. Subscriber Name B. Subscriber Date of Birth C. Subscriber Address D. Subscriber Telephone Number E. Policy Number F. Group Number G. Employer Referral source Front of Insurance Card Back of Insurance Card Submit Form
