We Accept Most Insurance.

Note that many of our clients (business owners and parents covering their children) choose to to self pay. We can help you with either option you choose.

Just fill out the form below with all the information you have. We will get back to you ASAP and let you know what is covered. Questions? Call us at 866-933-9777.

Self Pay? Just skip this form and call us. We will take care of everything.

Your Name:
Phone:
Email:
Address 1:
Address 2:
City:
State:
Zip code:
Age:

Comments or Questions:

Drug being used:
Payment Method:
Transportation needed??	Yes no
Your insurance Provider:
Patient Name:
Patient Date of Birth:
Policy Holders name:
Policy Holders DOB:
Relation to patient:
Insurance ID number:
Insurance phone number:
Have they been though drug or alcohol treatment before?	Yes no