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Please complete the form below and someone will be in touch with you shortly.
We can help you find treatment,
call
1-877-662-0828
for help
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Your First Name:
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Please Describe The Individual Needing Treatment
Who Is the Treatment For?
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Name Of The Person Seeking Treatment:
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Does This Person Want Help?
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Does This Person Have Insurance?
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Yes - PPO
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How Much Money Is Available?
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$5,000 - $10,000
$10,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
More than $50,000
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