Addiction Treatment Centers in South Florida



	New Dawn Recovery is a place where you can feel safe and secure, away from daily stressors to focus on yourself, and begin your journey into recovery.

	Our clients reside in a comfortable, upscale, independent living environment and are supervised 24 hours, 7 days a week by trained staff.

ADDICTION TREATMENT CENTER ADMISSIONS - NEW DAWN RECOVERY- DRUG AND ALCOHOL TREATMENT CENTER

Addiction Treatment Center Admissions Form

The first step toward treatment at New Dawn Recovery is completing this form. An Admissions Specialist will review your use history and insurance benefits and call to schedule an admission assessment.

If you cannot complete this form, or need assistance in completing this form, please call an admissions specialist at New Dawn Recovery to provide the necessary information.

Please note that we would like to receive all fields filled-in but the "*" fields are required. The information provided will be used only by New Dawn Recovery. All information will be kept secure and confidential.

ADMISSIONS FORM

Please Provide Your Information Below:

Date:

*Full Name:

Address:

*City:

*State

Zip Code:

*Home Phone:

*Work Phone:

Cell Phone:

Relation to Patient:

E-mail Address:

Message:

Patient Information (If different from above):

*Full Name:

Address:

*City:

*State

Zip Code:

*Home Phone:

*Work Phone:

Cell Phone:

E-mail Address:

Employer:

Primary Care Physician:

DOB (mm/dd/yyyy):

Gender:

Marital Status:

Primary Insurance Company:

Company Name:

Contact Number:

Member Policy Number:

Group Number:

Plan:

Effective Date:

Secondary Insurance Company:

Company Name:

Contact Number:

Policy Number:

Group Number:

Plan:

Effective Date:

Insured Party :

Insured Name:

Relation to Patient:

Date of Birth: (mm/dd/yyyy)

Currently Employed?

If Yes, How Long?:

If Not Employed, Termination Date: (mm/dd/yyyy)


Our Facilities

Addiction Treatment Programs

> Partial Hospitalization > Intensive Outpatient > Transitional Treatment > Extended Care > Continuing Care > Individual Treatment Programs > Family Treatment Program > Interventions
Addiction Treatment Services

> Drug Rehab > Alcohol Rehab > Dual Diagnosis > Relapse Prevention > Medical Issues Group > Medication Mngmt. > Behavior Modification > Eating Disorders Treatment > Gambling Addiction Treatment
Educational Activities

> Family Workshops > Relationship Workshops > Life Skills Training
more>>
Health & Wellness Activities

> Fitness Training and Wellness > Nutrition/Dietary Consultation > Spirituality Ethics In Recovery > Health Workshops/Groups > Massage Therapy > Yoga
more>>

Alcohol Rehab - Heroin Rehab- Crack Cocaine Rehab - Marijuana Rehab - Inhalants Rehab- Opium Rehab - Ecstasy Rehab
Prescription Drug Addiction Treatment - Ambien Rehab - Ativan Rehab - Methamphetamine Rehab - Oxycontin Rehab - Valium Rehab - Xanax Rehab - Vicodin Rehab - Klonopin Rehab
Eating Disorders Treatment - Co-occurring Disorders Treatment - Dual-Diagnosis Treatment