Confidential Self Assessment Form

Complete the following questions to confirm eligibility for medical detox

Please add date of birth

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Over 12 weeks pregnant?

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Had Detox treatment before?

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If had detox before, experienced:

Withdrawal seizures

Delirium Tremens

Admitted to ER/Hospital in last 3 months

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Please indicate which Gallus location you are interested to go to

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Unfortunately, we do not accept Medicare, Medicaid, or TriCare insurance, but we do offer financing options to make care more accessible. 50% of our patients self-pay (don’t use health insurance), and 50% use out of network commercial insurance to pay for treatment. We offer a discounted self-pay rate with an average patient responsibility of $8,500 (excluding insurance payments for deductibles, and coinsurance, and out of pocket maximums). Are you confident in your ability to pay for treatment?

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Full name

Title

Phone number

Email

Referring treatment center (if applicable):

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Please indicate the amount, frequency, and duration

SUBSTANCE
STRENGTH / AMOUNT
FREQUENCY
DURATION

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SELF ASSESSMENT FORM

We’re not sure if we can help, but we are happy to provide more information.

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Please choose the best way for our admissions team to connect with you:

Or contact our admissions team directly by calling 888-306-3122

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