New Patients

Below are a list of links to forms you will need to fill out and sign before we can schedule an appointment. Please complete the patient intake form and Consents. Once completed you will be contacted to schedule an appointment.

Start Recovery Now

CRISIS LINE

988 Emergency 911

Name*

Preferred Name*

Birth Date*

Phone*

Email*

Social Security Number*

Client is a Minor*

Yes

No

Sex at Birth*

Male

Femal

Street Address*

Apartment

City*

State*

Zip Code*

Emergency Contact Name*

Relationship to Client*

Emergency Contact Phone Number

Insurance Carrier (write none if client does not have insurance) *

Member or Policy Number (Write none if client does not have insurance)*

Group Number*

Subscriber Information*

Subscriber is Client

Subscriber is other than client

Requested Services*

IOP intensive outpatient

PHP Partial Hospitalization Programing

Sober Living

Best way to reach you*

Any

Phone

Email

Text

Additional Information (Optional)

CONTACT

PHONE

HOURS

2400 Silvan Road West Terre Haute, IN,

rthomas@roadwaystorecovery.com

EMAIL

(812) 420-9090

LOCATION

MON-FRI

9am-6pm

SAT-SUN

By Appointment

New Patients

Start Recovery Now

FOLLOW US

CONTACT

HOURS

LOCATION