Admissions Inquiry

Ashley’s admissions staff is here for you.

We work hard every day to make your admissions process as easy and quick as possible. Have peace of mind knowing that your personal information will always be kept confidential. Our committed team is prepared to guide you through every stage of the process.

General Information

Name(Required)

First name of form submitter Last name of form submitter

Relationship to Patient(Required)

Email Address(Required)

Address

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

Phone

(Only list the numbers that we can use to contact you) If you would like to contact us instead, do not leave your phone numbers. Please contact our Admissions Department: 800-799-4673 x213.

How did you hear about Ashley Addiction Treatment?(Required)

Patient Information

Patient Name(Required)

First Name of Patient Last Name of Patient

Patient Date of Birth(Required)

Marital Status

Patient Street Address

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

Insurance Information

If you would like Ashley to verify your insurance plan benefits, please provide your medical / mental health insurance information below. All information is required. On occasion, more information is required to verify insurance benefits and eligibility. All information below is required in order for Ashley to verify insurance plan benefits.

Insurance Company Name(Required)

Insurance Company Phone Number(Required)

Subscriber Name(Required)

Subscriber Date of Birth(Required)

Relationship of subscriber to patient:(Required)

Name of subscriber employer:(Required)

Member ID number:(Required)

CAPTCHA

Frequently Asked Questions

What happens after I submit the admissions inquiry form?

After you submit the form, a member of Ashley’s Admissions team will contact you to learn more about your situation and answer any questions you may have. During this conversation, we may complete a brief assessment, review treatment options, and discuss insurance coverage or expected costs. Our goal is to help you understand whether Ashley is the right fit and guide you through the next steps.

How quickly can someone be admitted to treatment?

Once an admissions assessment is completed and Ashley is confirmed to be a good clinical fit, admission can often be scheduled quickly—sometimes the same day depending on availability. Our Admissions team is available 24/7 to help individuals and families begin the process as soon as possible.

Who is eligible for treatment at Ashley?

Ashley provides treatment for adults age 18 and older who are seeking help for substance use disorders and co-occurring mental health conditions. During the admissions assessment, our team determines whether we can safely and appropriately meet the individual’s needs.

Does Ashley accept insurance?

Ashley works with many insurance providers and can help verify your benefits during the admissions process. If you submit this form and provide insurance details, our team can review your coverage and explain any potential out-of-pocket costs before admission.

Can I complete this form for a loved one?

Yes. Many people contact Ashley on behalf of a spouse, family member, or friend. Our Admissions specialists are experienced in helping families navigate treatment decisions and can guide you through the next steps for getting your loved one the help they need. However, to move forward with admission, we will need to speak directly with the potential patient to complete the clinical and medical assessment process.