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Who would be receiving care?

Your info

Select the state you live in
Do you live in an apartment, house, duplex, other
Reason for care
Is yes, please list approx date of last attempt.
Is yes, please list approx date of last attempt.
Is yes, please list drug names and approx weekly frequency of use.
Please answer yes even if you consume alcohol during the year socially. This assists the agency in identifying potenital symptoms stemming from medication interactions with alcohol use.
Administrative
If referred for services, please list name of referring provider or agency.
Billing & Payment
Please list insurance provider name, policy number and group number.
Limited to 600 characters
Client Preferences
Please indicate all preferred appointment times to give the best success at scheduling soonest.
For example: what you'd like to focus on, insurance or payment questions, etc.
Limited to 600 characters

If you or others are in immediate danger or experiencing a medical emergency, call 911 immediately.

By submitting this form, you agree to the processing of your sensitive personal information, which may include protected health information (PHI). This information may be viewed by team members in this practice.