Detox / Withdrawal Management Questionnaire Please fill out the information below if you think you could benefit from Detox/Withdrawal Management 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 After hitting 'submit', you will be contacted by our Detox Referral Manager within 1 Business Day. Know that you are NOT alone!