| Items for Admission | Name, address, and phone # of Probation Officer if applicable |
| Name, address, and telephone # of patient | Name, address, and phone # of lawyer if applicable |
| Birth Certificate | Name, address, and phone # of person and agency that made referral |
| Social Security card | Home school and Alternative school’s name (if applicable), |
| All insurance and Medicaid information | Include school address, phone #, along with names of guidance counselor and principal |
| Include a copy of the cards; if more than one insurance, please include all. | Name, address, and phone # of outpatient and any other drug/alcohol treatment services which the patient has received |
| Tuberculin Skin Test/PPD results (if had the test in the last year) | Previous year tax statements indicating Adjusted Gross Income |
| Name, address, and phone # of legal guardian | Legal Status |
| Name, address, and phone # of Primary Care Physician | Co-Pay, if applicable |