Full Name
*
Email
*
What substances are you currently struggling with? (Select all that apply)
Alcohol
Opioids (Heroin, Fentanyl, Pain Pills)
Methamphetamine
Cocaine
Benzodiazepines (Xanax, Valium, etc.)
Prescription medication misuse
Multiple substances
Others
When was your last use
Within the last 24 hours
Within the last 3 days
Within the last week
More than a week ago
Have you experienced withdrawal symptoms when trying to stop?
Yes – mild (anxiety, sweating, nausea)
Yes – severe (shaking, seizures, hallucinations)
No
Not sure
Has your substance use affected your home life, relationships, or employment?
Yes – significantly
Yes – somewhat
No
I’m not sure
Have you experienced an overdose, hospitalization, or medical emergency related to substance use
Yes – within the last 30 days
Yes – in the past year
No
Are you currently feeling severely depressed, hopeless, or having thoughts of harming yourself or others?
Yes
No
(If yes, please call 911 or go to the nearest emergency room.)
Have you been diagnosed with depression, anxiety, PTSD, bipolar disorder, or another mental health condition?
Yes
No
Unsure
Have you tried outpatient treatment or rehab before?
Yes – multiple times
Yes – once
No, this would be my first time
Is your current living environment supportive of recovery?
Yes
Somewhat
No – substances are present
I do not have stable housing
Are you willing to commit to a structured 35-day residential program focused on recovery and stabilization?
Yes
Possibly – I need more information
Not sure
Do you have health insurance?
Yes
No
Not sure
On a scale of 1–10, how ready are you to make a change?
1 2 3 4 5 6 7 8 9 10
What is the biggest reason you are seeking help right now?
Submit