Online Pre-Intake Form
Horizon Treatment Center
24901 Northwestern Hwy Ste 412, Southfield, MI 48075-2302
248-423-1728 (Office) & 248-423-1734 (Fax)
Website created by Smith - contact webmaster@Horizontreatment.org for website issues.
Copyright © 2020 Horizon Treatment Center.  All Rights Reserved.
Welcome to our New Online Pre-Intake Form
Complete & submit. You will be contacted within 24 hours with your scheduled Intake appointment
Age
Name:
 Birthdate
Phone #
Address:
Email Address:
Services sought:
Your Insurance:
If yes, for what?
Past Therapy HX?
If yes, explain:
Suicidal/homicidal?
If yes, explain:
Are you on probation?
When would you like to schedule your Intake?
Questions, comments, or feedback: