Assessment Form | Fire Mountain Residential Treatment Center

Main contact and quote form

Do not fill this form out if you're a solicitor.
Parent Name*
First Last
Email*
Phone*
Teen Name
First Last
Age*
Birth Date*
Date Format: MM slash DD slash YYYY
Are you and this teen's other parent still married? If no, please explain the custody agreement here.
Address*
City State / Province / Region
Issues*
Official Diagnosis
Allergies (food, environmental, pet, etc.)
Does your child have any dietary restrictions or a history of an eating disorder?
Insurance*
- Yes
- No
Type Of Insurance
Additional Information
How did you hear about us?
Comments
This field is for validation purposes and should be left unchanged.