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General Information
Who Is This For?*
Patient Full Name*
Patient Date of Birth*
Patient Social Security #
Subscriber Full Name
Subscriber Date of Birth
Subscriber Social Security #
Email*
Home/Cell Phone Number*
How did you hear about us?*
Address
Address on file with your insurance carrier.
Street Address*
City*
State*
Zipcode*
Insurance Information
Insurance Carrier*
Insurance ID #
Provider Services Phone # (on back of card)*
Group ID #
Type of Plan
- PPO
- HMO
- EPO
- POS
- Unknown
Is this a COBRA Policy?
- Yes
- No
- Unknown
Additional Information
Have You Been to Treatment Before?
Brief Description of Your Problem
Comments
When and how is the best way to contact you?

Get Help Now

If you or a loved one has a substance addiction, please give us a call today at 844-252-5221. It’s time to heal your heart and find true happiness.

Our admissions team is always available to talk and answer any questions you may have about our Drug and Alcohol Rehab Programs at Casa Capri Recovery for women.

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Casa Capri Recovery

Our program offers the highest quality care for women struggling with addiction and co-occurring conditions.

We are fully licensed by the State of California and our treatment center is accredited by The Joint Commission – the standard of excellence in quality programs.

Casa Capri Recovery is Proud to be an Approved Tri-Care Provider

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Accredited by:

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