Addiction Treatment Interest Form Please fill out the information below if you think you could benefit from Addiction Treatment Services. Your Name Your Phone Number Your county of residence Do you have insurance? If so, what kind? Please mark each substance that you’ve used in the past 7 days AlcoholHeroinPain PillsCannabisXanaxPoshCocaineCrackSuboxoneOther Please check which services you are interested in Detox/Withdrawal ManagementResidential ServicesOutpatient Services After hitting 'submit', you will be contacted within 1 Business Day. Know that you are NOT alone!