Online Scheduling

We understand that sometimes taking that first step can be the most difficult step to take. To schedule an assessment online please completely fill out this form and submit. Our caring and supportive staff will make every effort to schedule an appointment that is convienient for you. We will need to contact you with further questions and to confirm your appoinment.

First Name: *
Last Name: *
Middle Name: *
Address Street 1: *
Address Street 2:
City: *
Zip Code: *	(5 digits)
State: *
Primary Phone #: *
Cell / Work Phone:
Birthdate: *
Social Security #::
Email: *
Insurance:	Yes Insurance No Insurance
Insurance Provider::
Member ID::
Group Number::
Provider Telephone Number:
Ins. Policy Holder	Self Other
Policy Holder Name (if other than patient):
Relationship To Patient:	Mother/Father Other
Policy Holder Birthdate:
What is the reason for the assessment?:
Policy Holder Social Security #::
Please enter the most convienient time for your assessment. Assessments are scheduled Monday: 11am-4:30pm Tuesday: 2pm-4:30pm Wednesday: 1pm-4:30pm Friday: 11am-4:30pm
Best time of day to contact you:: *
How Did You Hear About Us?:
Email: *
Additional Concerns:

This information is strictly confidential and protected by

Federal Confidentiality rules (42 CFR Part 2).

Serenity Is Not Just A Dream

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Five Stars Recovery Center
102 East 2nd Street,Suite 110B
Chaska, MN 55318
952.448.6557
FAX 952.448.6047
information@fivestarsrecoverycenter.org

Serving Chaska, Shakopee, Waconia, Cologne, Norwood Young America, Eden prairie, Excelsior, Chanhassen, Jordan and Belle Plaine