Begin the recovery journey today.

Take a 5-minute assessment to see if we’re the right fit for you or your loved one.

What is the client’s name?

First Name(Required)

Last Name(Required)

Do you have health insurance(Required)

Yes

Is paying cash an option for you?(Required)

Yes

Does the client have private insurance? (e,g, PPO) (Required)

Yes

We only accept insurance through private payers. Is paying in cash an option for you?(Required)

Yes

Type of Insurance(Required)

Health Insurer Name(Required)

More Info(Required)

Client First Name(Required)

Client Last Name(Required)

Client Date of Birth(Required)

MM slash DD slash YYYY

Member ID Number(Required)

FRONT OF CARD

Max. file size: 50 MB.

BACK OF CARD

Max. file size: 50 MB.

However, we have attached links and resources to help you or your loved one find help.

Washington

Oregon

Please provide the best way for us to get in touch.

Contact Person Name (client, parent, friend, etc.)

Phone(Required)

How did you hear about us?(Required)

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