Pre-Registration Form — Astra Mental Health & Recovery

Welcome!

We know how tough it is to live with mental health or substance use challenges. All of us at Astra Mental Health & Recovery want the best for you and your family. Whether you live with anxiety, depression, ADHD, trauma, substance use or other challenge, Astra is here to assess what’s going on and provide the appropriate treatment.

The fastest, easiest way to get started is to pre-register. Once you complete the form and click “Submit,” an Astra staff member will call to set your first appointment.

Fill in the spaces below and click “Submit” when finished to send your form to us. Astra Mental Health & Recovery Admissions will contact you to help you get started. (NOTE: An asterisk * indicates required information.)

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Pre-Registration Form

"*" indicates required fields

First name*

Last name*

Person seeking services*

Yourself

Your child

If child, child's first name

If child, child's last name

Best phone number to call*

Best time to call between 7:30 a.m .and 5 p.m.*

Who referred you for services?*

What are your concerns?*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

E-mail of person seeking services*

Date of birth for person seeking services*

School, if applicable

Current grade, if applicable

Doctor's name

Insurance Information

Do you have insurance?

Yes

Insurance Policy

Insurance Company

Insurance ID#

Insurance Group #

Insured Name

Insured Date of Birth

Insured Employer

Insured Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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Name

This field is for validation purposes and should be left unchanged.

Pre-Registration Form — Astra Mental Health & Recovery

Welcome!

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Pre-Registration Form

Insurance Information

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Address

Phone