Online Admissions Pre-Approval

Online Admissions Pre-Approval

We dedicate ourselves to ensuring that those who come to Top of the World Ranch are successful in the program and beyond. This online admissions process form is the first step to that goal. We understand it is a long process, and it can be frustrating at times. We ask that you answer each question the best that you can. You have already taken a large step in getting to this point. Do not stop now. You can always call us at 1.844.814.8885 for assistance. We look forward to serving you. You are worth it. You can change, and so can your circumstances. Complete the form below to begin the enrollment process.

1.844.814.8885

Step 1 of 4

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First Name and Last Name(Required)

What is the client's current mailing address (city, state, zip code)?(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Are you planning on utilizing your insurance, or opting to private pay?

Insurance

Private Pay

Do you have any form of Medicaid or Medicare (primary or secondary)?

Yes

Im Not Sure

Sorry we do not take medicaid medicare. To discuss your options for treatment, please call us at 1-844-814-8885

Please provide your insurance information or if you do not have it readily available you can email it to [email protected] or call us at 1-844-814-8885 to provide us with the information prior to approval.

Name of Your Insurance Carrier

Name of the Policy Holder

Policy Holder DOB

Member ID

Group #

Phone Number for Behavioural Health (found on the back of your card)

Do you have any form of active schizophrenia, active eating disorder, active suicidal or homicidal thoughts outside of your substance use?

Yes

Please contact us at 1-844-814-8885 And reach out to the national suicide prevention line 1-800-273-8255 if you’re currently experiencing thoughts of suicide or self harm. Thank you.

Do you have any mobility issues? (i.e. troubles walking up and down stairs, distance walking between buildings etc.)

Yes

Sounds like we aren’t a fit for your choice of treatment. You can call us at 1-844-814-8885 to discuss further options.

You've been pre-approved for admission into Top Of The World Ranch*. Please provide us with your email and phone number to receive the next steps in the process. *If you have not provided us with your insurance, please be advised this pre-approval is contingent on your insurance benefits and general fit for our program. We look forward to speaking with you!

We will reach out to speak about your insurance and help you figure out approval. Thank you!

Potential Client's Email

Potential Client's Phone Number(Required)

Alternate Phone Number (if applicable)

Emergency Contact Name and Relationship to Potential Client

Emergency Contact Email

Emergency Client's Phone Number(Required)

Do you grant us permission to contact, you, the potential client?(Required)

Yes

Do you grant us permission to contact your emergency contact?(Required)

Yes

If we cannot reach you via phone, can we text the number provided?(Required)