Personalized & Supported Treatment Solutions

Let Us Help You Find the Best Addiction Treatment Solutions That Work for Your Loved-One!

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Don’t worry if you don’t know all the answers. Do your best and let us help your loved-one begin their journey together.

Your Name

Your Email

Your Telephone

Client Name

Client Telephone

Client Email

Been to Treatment Before?

Do They Need Detox?

Do They Have Insurance?

Type Of Insurance:

Length of Use:

Are They Employed?

Any Outstanding Legal Issues?

Co-Occurring Mental Illness?

Anything Else You'd Like Us to Know?

Terms & Conditions

Except as otherwise stated in this Privacy Policy, we do not sell, trade, rent or otherwise share for marketing purposes your Personal Information with third parties without your consent. We do share Personal Information with vendors who are performing services for the Company, such as the servers for our email communications who are provided access to user’s email address for purposes of sending emails from us. Those vendors use your Personal Information only at our direction and in accordance with our Privacy Policy.