Judy Retterath Withdrawal Management Center Intake Form Please fill out this form to indicate your interest in becoming a Judy Retterath Withdrawal Management Center client. FacebookThis field is for validation purposes and should be left unchanged.Name First Last Date of birthDo you have health insurance? Yes No Commercial or State health insurance?Commercial health insurance is health insurance provided and administered by nongovernmental entities. You may have coverage through your employer or insurance broker. State health insurance is provided and administered by governmental entities. You may have coverage through Medical Assistance, Minnesota Care or Medicare.CommercialStateInsurance ProviderGroup numberMember numberWhere do you currently live?County or CityHave you used substances in the past week? Yes No What substances were you using?Where did you last use substances?County or CityAre you pregnant? Yes No How far along is your pregnancy?May we email or call you and leave a message?(Required) Do Not Contact Email Only Phone Only Email or Phone Email(Required) Enter Email Confirm Email Phone(Required) Δ
