Close
Home
Our story
contact
APPLY FOR CONSIDERATION
Apply
Client Waitlist & Pre-Registration Form
NOTICE: This facility is currently undergoing renovation and is not yet open to the public. Completion is estimated within 9–10 months. Submitting this form does not guarantee immediate services, but ensures you will be contacted when client intake begins. Your information will be securely stored in accordance with HIPAA and Arizona Department of Health Services (ADHS) Title 9 confidentiality standards.
Name
(Required)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Phone
(Required)
Email
(Required)
Mailing Address
(Required)
Street Address
Address Line 2
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
ZIP Code
Emergency Contact Information
Name
(Required)
First
Last
Phone
(Required)
Email
(Required)
Relationship to Client
(Required)
Insurance and Prior Authorization Pre-Verification
Insurance Provider:
(Required)
Policy Number:
(Required)
Group Number:
(Required)
Member ID:
(Required)
Subscriber Name:
(Required)
Subscriber Date of Birth:
(Required)
MM slash DD slash YYYY
Provider Services Phone #
(Required)
Pre-Auth Number (if available)
Consent
(Required)
I hereby authorize Breaking Habits, LLC to retain the personal and medical information provided on this form for the purposes of pre-enrollment and service coordination. I understand that this information will be handled in accordance with all applicable federal HIPAA laws (45 CFR Parts 160 and 164) and Arizona Department of Health Services confidentiality requirements under Title 9. I may revoke this consent at any time in writing.
I agree to the privacy policy.
(Required)
Signature
(Required)
Printed Name:
(Required)
Date
(Required)
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.
