SUD Treatment Group Interest Form

Substance Use Treatment Groups ~ Interest Form
Thank you for your interest in joining the Substance Use Disorder (SUD) Treatment Groups at Healing Reins! After you submit this form, you will be contacted the program manager, Lisa Bradley, the same or next business day.
Name:*

First NameLast Name
Current Age*
Date of Birth*

MonthDayYear
Date
Legally authorized parent or guardian - (if the person interested in the SUD group is a minor)*

First NameLast Name
Best contact phone:*

Area CodePhone Number
Best Contact Email*
example@example.com
Does the proposed time on Wednesdays from 10am - 12pm (starting January 4, 2023) work for you?

YesNot ideal, but I can make it workNo

When is good for you (check all that apply)?

Substance Use Treatment Groups ~ Interest Form