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Drug Use

Living Arrangements


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Tell us a little about yourself.

My name is

Date of Birth (DOB)

What best describes your current situation?

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)


What other type of drug?


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)?

Marital Status



Benefits Check

Do you or your loved one have insurance?

Insurance Carrier:

Insurance Type:

Group Number:

Policy Number:

Please enter your contact information.

Full Name


Phone Number