New Contact Us Form "*" indicates required fields HiddenformId I Am:* Looking for Services for Myself Referring a Loved One A Provider Referring a Client Please Provide Us with Your Information: Your Information Your First Name:* Your Last Name:* Your Phone Number:*Your Email Address:* Address: City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Title:* Organization:* How did you hear about us?* Internet Search Social Media Healthcare Professional Family Member / Friend Employer Other Please Provide Us with Your Loved One's Information: Loved One's (Client) Information Please Provide us with Your Client's Information: Client's Information Client's First Name:* Client's Last Name:* Client's Date of Birth:* MM slash DD slash YYYY Client's Address: City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client's Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Client's Relationship to you:* Child Sibling Spouse/Partner Friend Other What type of service(s) is the client seeking?* Mental Health Substance Use / Addiction / Alcohol Other What kind of support do you need? (select all that apply)* Mental Health Substance Use / Addiction / Alcohol Other What is the client's primary need?* Mental Health Substance Use / Addiction / Alcohol Other Which level of care are your recommending for the client? (select all that apply)* Therapy & Counseling Outpatient Programming (OP) Intensive Outpatient Programming (IOP) Medication Assisted Treatment (MAT) Is the client seeking help related to service in the military or as a first responder?* Yes No Family member of a Veteran or First Responder Are you seeking help related to service in the military or as a first responder?* Yes No Family member of a Veteran or First Responder How do they identify?* Military Veteran Active-Duty Military First Responder Retired First Responder How do you identify?* Military Veteran Active-Duty Military First Responder Retired First Responder This Section is Optional, but can Help Streamline the Admission Process: Client Insurance Information Client's Insurance Provider: Client's Member ID: Client's Email: Client's Phone Number:Discharge Paperwork Upload Option Drop files here or Select files Max. file size: 2 MB, Max. files: 4. Tell us a little more about the client and their current needs:I give or have obtained any necessary consent/authorization prior to disclosing the health information above.* Yes Tell us a little more about how we can best support you:I consent to receiving communications via telephone, email, and SMS/text, as appropriate.* Yes CAPTCHA
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