Apply NowWe encourage you to contact us by phone (call or text) to discuss your needs before completing this application. We look forward to hearing from you! Primary Contact Information We often process applications on behalf of a loved one. If you are not the applicant, please complete this section. If you are the applicant, skip and proceed to 'Applicant Information'. First Name Last Name Primary Contact Phone (###) ### #### Primary Contact Email Applicant Information * First Name Last Name Applicant Email * Applicant Phone (###) ### #### What are you looking for? * Check all that apply MAT-friendly facility Long-term recovery facility Something else Can you afford the first two weeks ($475)? * No, I would need a scholarship Yes, I can cover the initial fees How did you hear about us? Doctor or other professional Internet search From a friend/loved one How can we help? * Which (if any) medications are you currently prescribed? Thank you!
