RMA Client Information Form

Please complete the form below to begin the process

Contact Information

First Name

Middle Name

Last Name

Nick Name

Prefix

Suffix

Birthdate

Gender

Pronouns

Phone

Address

City

State

Zip

Current Status

Are you contacting us about yourself

If not, who are you contacting us about and what is your relationship

Who will be financially responsible

Relationship

Phone

Occupation / Student

If a minor, guardian's name

Guardian's Phone

If student, school currently attending

Year in school

Current insurance

Insurance member ID #

Group #

Name of insured party

RMA is acting as a consultant company, and therefore does not accept insurance. While many clinicians/treatment centers do accept insurance, many do not.

Are you solely insurance dependent

Medical History

What concerns have prompted this appointment

History of hospitalizations / ER visits (with dates)

History of residential or outpatient treatment (with dates)

Briefly explain any outstanding legal issues

Attorney's name (for related legal issues)

Attorney's phone

Current psychiatrist

Psychiatrist's phone

Current therapist

Therapist's phone

Primary medical doctor

Medical doctor's phone

Other doctors

Other doctors' phone

Currently prescribed medications/dosages/length of time taken

Current OTC medications/dosages/length of time taken

Current/Past diagnoses (if any)

How did you hear about Recovery Management

Referred by

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RMA Client Information Form

Please complete the form below to begin the process

Contact Information

Current Status

Medical History

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