Admissions

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Admissions

Name

Relationship To Client

Referred By

Client’s Full Name

Client’s Date Of Birth

Client’s Age

Gender

Client’s Address

City

State

Zip Code

Client’s Phone Number

Insurance Company

Plan Type

Member ID Number

Group Number

Insurance Company Phone Number

Has Client Been To Treatment Before? If yes, where?

Additional Notes

Begin your recovery journey with care that’s tailored to you—delivered by a team of compassionate and experienced addiction treatment professionals who are committed to your healing. At Maplewood Treatment Solutions, we understand that no two paths to recovery are the same. That’s why we create individualized treatment plans that address your unique challenges, goals, and strengths—helping you build a healthier, substance-free future.

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