Find the Right Support for Detox

If you or someone you love is looking for help with substance use, we’re here to help. Answer a few questions so our admissions team can better understand your needs and connect you with the appropriate detox support.

Help us match you to the right treatment

It’s important to have a team who you can establish a personal connection with. The following questions are designed to help match you to a team and treatment program designed for your needs and personal preferences.

Who is this for?

First name

Last name

Phone number

Email address

Best time to reach you

Date of birth

Gender identity

Pronouns

What state do you live in?

City & ZIP code

City & ZIP code

Preferred language

How are you planning to pay for treatment?

Insurance company

Are you the primary policyholder?

Policyholder's relationship to you

Insurance card upload (front)

Optional. Upload a clear photo if available.

Insurance card upload (back)

Optional. Upload a clear photo if available.

Member/Subscriber ID

Policyholder's employer

What substance(s) are you seeking help for?

How long has this been a concern?

How often are you currently using?

When did you last use?

Tell us a bit about what's going on right now

Have you ever had a seizure related to stopping or cutting back on drugs or alcohol?

Have you ever experienced hallucinations, severe shaking, or confusion when you stopped using (sometimes called “the DTs”)?

Have you ever had an accidental overdose?

Do you ever lose memory of periods of time while using (“blacking out”)?

Have you received treatment for substance use before?

Roughly when, and what type of program?

Roughly when, and what type of program?

Are you currently taking, or have you taken, medication for cravings (e.g. Suboxone, Vivitrol, Naltrexone)?

Have you ever been diagnosed with a mental health condition?

Which condition(s), if you are comfortable sharing

Are you currently taking any prescription medications?

Please list them

Do you have any medical conditions we should be aware of?

Any medication or food allergies?

Do you currently have a primary care doctor, therapist, or psychiatrist?

In the past few weeks, have you had any thoughts of harming yourself or someone else?

Have you noticed any recent changes in your eating or appetite?

What does your current living situation look like?

Do you have people in your life who are supportive of you getting help?

Are you currently employed or in school?

If yes, tell us more (optional)

Do you have any current legal issues we should know about?

Is the person seeking treatment under any legal guardianship or conservatorship?

Emergency contact name & phone number

Emergency contact name & phone number

Anything else you would like us to know before we call you?

If you or someone you know is in immediate danger, call or text 988 (Suicide & Crisis Lifeline) or call 911.

If you or someone you know is in immediate danger, call or text 988 or call 911.

Need immediate help?

If you or someone you know is experiencing an emergency or is in immediate danger, please call 911 or call or text 988. For any medical emergency, please seek immediate medical attention.