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About Us
Meet Our Team
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Detox Treatment
Residential Treatment
Day Treatment
Age-Specific Outpatient
Evening IOP Treatment
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Please fill out the form below and we'll be in touch with you as soon as we can.
Tell us a little about yourself.
Full Name
Date of Birth (DOB)
Email
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What best describes your current situation?
I am struggling with addiction and need help.
My loved one has addiction issues, and I don't know what to do.
Describe what you or your loved one is struggling with right now.
What type of drugs are you or your loved one using? (Please click all that applies.)
Alcohol
Benzodiazepines
Cocaine
Heroin
Meth
Opiates
Sleeping Pills
Stimulants
Other
What other type of drug?
Frequency
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- Multiple Times a Day
- Socially
- I don't know
Who do you (or your loved one) currently live with?
Do you (or a loved one) live with someone/people who use or abuse substances?
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- I don't know.
- Yes
- No
Marital Status
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- Single
- Divorced
- Married
Children
No
Yes
Employment
Employed
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Do you or your loved one have insurance?
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No
Insurance Carrier
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- Aetna
- Anthem
- Beacon
- Blue Cross Blue Shield (BCBS)
- Cigna
- Emblem Health
- Humana
- Medicaid
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- Tricare
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Insurance Type
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- PPO
- HMO
- EPO
- Other
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