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Confidentiality Notice:
By completing this application, you are initiating services with Stages of Recovery, a federally covered program. Information you provide is protected under the Health Insurance Portability and Accountability Act (HIPAA) and 42 CFR Part 2, which governs the confidentiality of substance use disorder patient records. This includes your name, contact information, responses to screening questions, and any substance use history or treatment-related details you share.

Personal Information

Name (as shown on your ID)

First Name

Last Name

Phone *

Email *