"
*
" indicates required fields
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X
X
X
X
X
X
I need treatment for…
Treatment
*
Myself
A Loved One
What’s your timeframe for getting help?
Timeframe
*
Immediately
Within a week
I need treatment for…
Select each that applies
*
Substance Abuse
Mental Illness
Dual Diagnosis
Substance Abuse
*
Select all that apply
Alcohol
Amphetamines
Benzos
Cocaine
Kratom
Meth
Marijuana
Opiates
Other
Mental Illness
*
Select all that apply
ADHD
Anxiety
Bipolar Disorder
Borderline Personality Disorder
Depression
Eating Disorders
OCD
PTSD
Schizophrenia
Suicidal Ideation
Trauma
Other
Dual Diagnosis
*
Select all that apply
Alcohol
Amphetamines
Benzos
Cocaine
Kratom
Meth
Marijuana
Opiates
ADHD
Anxiety
Bipolar Disorder
Borderline Personality Disorder
Depression
Eating Disorders
OCD
PTSD
Schizophrenia
Suicidal Ideation
Trauma
Other
How do you plan to pay for treatment?
Plan Pay
Private Health Insurance (HMO / PPO)
Self Pay
State Funded Insurance (Medicare / Medicaid)
No insurance or financial resources
If you stop using will you experience physical withdrawal?
Withdraw
Yes
No
Not applicable
Select a location
States
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
How can we contact you?
Full Name
*
First
Phone Number
*
Please do NOT put a 1 before the area code
Email