Client Information

First Name *

Last Name *

Phone Number

PMI NUMBER *

Individual ID number: *

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Date of birth

Emergency Contact Person

First Name *

Last Name *

Phone Number

Relationship

Referred By:

First Name *

Last Name *

Phone Number

Agency/Org Name

Reason for Referal:

Referal type

Upload file(if necessary use the input below to add more)

Please remember to send along the Diagnostic Assessment (DA), Release of Information (ROI), Insurance information, H&P (from the hospital), and Medication list. Better Life Inc. Intake staff will reach out within 48 hours of us receiving the information to complete a phone interview. Thank you!

By submitting this form you agree to the terms of the Privacy Policy

Referal Form

Client Information

Emergency Contact Person

Referred By:

Reason for Referal: