Are you seeking treatment?
Yes, urgently
Yes, within a month
No, just exploring
Who needs the treatment?
Myself
A loved one
Both
What type of program interests you?
Inpatient
Outpatient
Detox
Counseling
When do you prefer to start?
Immediately
Within a week
In a month
Not sure yet
What support do you value most?
Medical care
Emotional counseling
Peer support
All of the above
How did you hear about us?
Internet search
Friend/Family
Healthcare provider
Other
All set, how can we reach you?
Name
Email
Phone
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