Addiction Treatment Interest Form Your Name Your Phone Number County of Residence 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? ---yesno After submitting, you will be contacted within 1 business day. Know that you are NOT alone!