Client Forms
Intake Form
New clients must fill out this form packet in its entirety. The forms include questions about yourself, your family, your drug use, your health insurance (or lack thereof), and psychological/behavioral problems you may be experiencing. There is also information about fees for our services and our billing process.
AWARE Driver Intervention Program Form
These forms are to register for our AWARE program. AWARE is a 72-hour residential driver intervention program for first-time DUI offenders that serves as an alternative to jail sentencing. This program is conducted in association with local drug courts.
Income Verification Form
If a friend or family member (excluding a spouse) is referring an individual to LARC for treatment, they can submit this form to ensure that they are not held financially responsible for the named person’s treatment-related expenses.
Good Faith Estimate for Health Care Items and Services
Expected charges include services and items for this episode of care only, it does not include additional recommended treatment once the original recommended treatment is completed and/or if change in level of care is needed or requested. Additional Good Faith Estimate will be provided upon request.