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This information was VERY helpful,
probably even life-saving!
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Comments and Questions

You may contact us by filling out our question/comments form below. All information you submit using this form is completely confidential.

* required fields
your name
phone number
*e-mail address
*please re-verify exact
e-mail address
this request is for myself   family member    friend
at this point, are they ready and willing to go to rehab? yes   no   maybe
 
preferred geographic location(s)
city or cities
state or states

*zipcode
willing to consider other possible options / locations yes    no    maybe   
level of care Detox
Inpatient (full time)
Outpatient (part time)
Not sure

person's age group

 

Adult – 24 and over
Young Adult – 18 to 24
Adolescent – 17 and under

dependency issues    Alcohol
Drugs
Medications
Other

mood disorders Depression
Anger
Bi-polar
Anxiety
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*insurance coverage

Medicaid
Medicare
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U.S. Military
State-financed (Tenncare, Medical, etc.)
Other ( please explain below )
None

If necessary , how much out-of-pocket funding might be available for private rehab ?

None
$1-$2,500
$2,500-$7,500
More than $7,500
Not sure

 

If necessary, is it ok to call you Yes
No

If yes, is it ok to leave a message Yes
No
Not Applicable



any and all additional facts and background information you feel is pertinent
 

NOTE: All information is protected by HIPPA (Health Insurance Portability and Accountability Act of 1996) regulations.

 

 


Contact Us by Phone

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If you or someone you know needs help, pick up the phone and call us right now:

1-800-784-6776