To enroll for any Maplegrove Treatment Center services, fill out the form below.

Participant Information

 

Emergency Contact Information

  • Person in case primary caregiver cannot be reached

 

Billing Information

  • ***This Section is for Private Insurance Participants Only***

  • If you are not funded through private insurance, skip this section and go to Participation Information below.
 

For Summer Program Participants

  • List any special considerations that we should be aware of with the participant: including diet restrictions, medical needs, and/or custody issues (all information will remain confidential).
 

Verification