Better Decisions Counseling Services
Name *
First Name Last Name
Gender *

Male Female
Age
Phone Number *
- Area Code Phone Number
E-mail
Date of Birth
/ Month / Day Year

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Legal Status
If Other, Please Specify
Insurance *
We don't accept Drug Medical
Which Insurance?
If Other, Please Specify
Policy holder name
Policy number
Treatment before?

Yes No
Physical Condition
Mental Status
Medication
Drug of Choice
Motivation for Treatment
Referred By
Notes
Should be Empty:

Counseling Center

Advanced Counseling Center

Sacramento Near Rancho Cordova

Call Us: (916) 368-0700

BetterDecisions
Counseling Services

Please fill in the following application

Join Our Mobile Group by texting BDCS to 40691