Using our Online Pre-Admission Form

Please enter your information on the following pages after an assessment has been completed by a therapist at Center for Change and a treatment center admissions date has been scheduled.  This form should take 10-15 minutes to complete.  You will need your insurance information.  The fields with a red asterisk (*) are required and must be completed in order for you to be able to submit the form.  If these fields are left blank, your registration will not be sent.  Information shared will help the admission process go much smoother on the actual day of admission.

Have I done a phone assessment with Center for Change?    YES   NO

Download Release of Information Here

Your Privacy

Center for Change assures protection of your personal information.  Our website securely transfers your information to our data systems.  You may read about our Privacy Policy and HIPAA requirements.  You can verify Center for Change is collecting your information over a secure site by clicking on the lock image at the bottom or top of this browser window to view our certification form.

To register with Center for Change as a client in the Intensive Outpatient Program (IOP) or to see an outpatient therapist or dietitian, click here: Outpatient Information Form