Apply For Admission Thank you for your interest in Wayside House, We truly look forward to helping you. Please fill out this small form or call us directly at 561-278-0055. Step 1 Your Name (required) Your Phone Number (required) Your Email (required) Your Address Your City Your State AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Your Zip Your Age Please Describe Any Symptoms Any other comments or questions? Type of care you are seeking? InpatientOutpatient What substances are you currently using? NoneAlcoholBenzosOpiatesMethadoneBarbituratesEcstasyMarijuanaCocaineOther Step 2 Method of Payment InsuranceOtherSelf-Pay Will you require transportation? YesNo Do you have insurance? YesNo Insurance Provider Patient Name Patient DOB Primary Policy Holder Name Primary Policy Holder DOB Relation To Patient Ins ID Number Substance Abuse or Mental Health Phone Number Have you been in treatment for drugs or alcohol previously? YesNo If yes, when and why? How did you hear about Wayside House? What is 3 + 2