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
Today's Date:

MonthDayYear
Is there anything else you'd like us to know at this time? *

0/75
Should be Empty:

Substance Use Treatment Groups ~ Interest Form