Skip to content
Home
About
About Us
Founder’s Story
Services
View All Services
Detox
Intervention
Relapse Prevention
Programs
View All Programs
Holistic Therapies
Executives (Adult Only)
Teen & Adolescent
Admissions
Facilities
Adult Only Facility
Teen Only Facility
Contact Us
Menu
Home
About
About Us
Founder’s Story
Services
View All Services
Detox
Intervention
Relapse Prevention
Programs
View All Programs
Holistic Therapies
Executives (Adult Only)
Teen & Adolescent
Admissions
Facilities
Adult Only Facility
Teen Only Facility
Contact Us
Get Help Now
(831) 245-1623
We’re Here To Help
Please fill out the form below and we’ll be in touch with you as soon as we can.
Drug Use
Living Arrangements
Payment
We're Almost Done!
Step 1
Step 2
Step 3
Step 4
Step 5
Tell us a little about yourself.
My name is
Date of Birth (DOB)
What best describes your current situation?
I am struggling with addiction and need help.
My loved one has addiction issues, and I do not know what to do.
Describe what you or your loved one is struggling with right now.
What type of drugs are you or your loved one using? (Please click all that applies)
Required
Alcohol
Benzodiazepines
Cocaine
Heroin
Meth
Opiates
Sleeping Pills
Stimulants
Other
What other type of drug?
Frequency
- Daily
- Multiple Times a Day
- Socially
- I don't know
What is you (or your loved one’s) current living situation?
Who do you (or your loved one) currently live with?
Do you (or your loved one) live with someone/people who use or abuse substances (illegal or legal)?
- Yes
- No
- I don't know.
Marital Status
- Married
- Divorced
- Single
Children
Yes
No
Employment
Employed
Unemployed
Benefits Check
Do you or your loved one have insurance?
Yes
No
Insurance Carrier:
- Aetna
- Anthem
- Beacon
- Blue Cross Blue Shield (BCBS)
- Cigna
- Emblem Health
- Humana
- Medicaid
- Medicare
- Tricare
- UMR
- UPMC
- UniCare
- United Healthcare
- I don't have insurance
- I'm paying out of pocket
- I don't know
- Other
Insurance Type:
- PPO
- HMO
- EPO
- Other
- I don't know
Group Number:
Policy Number:
Please enter your contact information.
Full Name
Email
Phone Number
SHOW SUMMARY
Some required Fields are empty
Please check the highlighted fields.
Submit
Previous Step
Next Step