Welcome Members

Uion

Taking the First Step

This form is confidential. Please complete the form below.

Please choose one of the options below*
Name of Client*
First Last
Policy/Member Identification Number*
Group Number*
Client Date of Birth*
Date Format: MM slash DD slash YYYY
Primary Policy Holder Name*
First Last
Primary Policy Holder Date of Birth*
Date Format: MM slash DD slash YYYY
Proposed Date of Admission*
Date Format: MM slash DD slash YYYY
Substances Being Used*
Medical Conditions*
Current Medications*
Best Contact Phone Number*
Best Pickup Address*
Street Address City State ZIP Code
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