A Better Today

Judy’s
Salesforce Form

Judy’s Salesforce Form

Fields marked with an * are required

(Patient's First Name, Last Name, Age and Gender ex. John Doe 25 M)

Caller Information




Caller relationship to Intended Patient:

Intended Paitent Information Intended Patient First Name:
Intended Patient Last Name:
Intended Patient DOB:
Intended Patient SSN:
Intended Patient Gender:
Is the IP insured?:
Pertinent Information:(Include the Referral Source in this field as well)

Insurance Information Patient Relationship to Subscriber:
Subscriber First Name:
Subscriber Last Name:
Subscriber SSN:
Primary Insurance Company:(If not in this list, enter it in the Pertinent Information field)
Type of Plan:(If not in this list, enter it in the Pertinent Information field)
Member ID Number:
Group Number:
Insurance Co. Phone:

Address Information




Find A Better Way With
A Better Today
888-906-0952

  • Confidential
  • 24/7
  • Financing Available
  • Most Insurance Accepted

ABT makes the recovery decision easy

Risk Free

Struggling with addiction is difficult, so why should your rehab be? ABT takes the risk out of the equation.

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Confidential

From the first phone consultation, to your rehabilitation and sobriety, ABT makes your privacy our number one concern.

ABT Guarantee

No one ever said that the journey into recovery would easy, but we have a promise. Complete our 90-day program and receive a 28-day tune up.

Need more help? Give us a call

SPEAK WITH A PROFESSIONAL

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Get Help Now (888)-906-0952

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Get Help now:
1-888-906-0952