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Alcohol or Drug Intervention Contact Form

Please note: All fields are optional; however, we do need at least one way to contact you. All information provided is treated with the strictest confidentiality. Without your express permission, except as expressly required by law, information is never shared with any other organization.

Your Name
Email Address
Phone Number
Best time & best way to contact you
Your relation to client
Age of client
Does client have health insurance?
Substance(s) used
Last time Substance was used
How long substance has been used
Treatment History: (In or out-patient, court ordered, 12step, state/country, when)
Please give us any other information about your situation that may help.

 


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