1.0 Contact Now - Card Format

1

Select all that apply - I am interested in:* This field is required.

Psychiatric Evaluation

Substance Use Evaluation

Individual Therapy

Medication Management

Medication Assisted Treatment (MAT)

Transitional Living Program

Sober Living Program

Substance Use Intensive Outpatient Program (IOP)

Transcranial Magnetic Stimulation (TMS)

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Please share with us whether you would like to seek treatment in-person, via telehealth, or either.* This field is required.

3

Name* This field is required.

First Name

Last Name

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Preferred Name* This field is required.

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Pronouns Used* This field is required.

he/him/his

she/her/hers

they/them/theirs

other

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Birth Date* This field is required.

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Email Address* This field is required.

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Cell Phone* This field is required.

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Signature* This field is required.