Addiction Treatment Interest Form

Your Name

Your Phone Number

Do you have Insurance? If so, what kind?

Please mark each substance that you have used in the past 7 days:
AlcoholHeroinPain PillsCannabisXanaxPoshCocaineCrackSuboxoneOther

Please check which services you are interested in:
Detox/Withdrawal ManagementResidential ServicesOutpatient Services

Are You Pregnant?
noyes
If yes, would you like to talk with someone about a Plan of Safe Care?
—Please choose an option—yesno

After submitting, you will be contacted within 1 business day. Know that you are NOT alone!

Δ