We're Here To Help

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

Phone

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

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?

Marital Status

Children

No Yes

Employment

Employed Unemployed

Do you or your loved one have insurance?

Yes No

Insurance Carrier

Insurance Type

Group Number:

Policy Number:

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