Healthcare/Service Provider Contact Form

Welcome. We’re very excited to work with you.

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* 1. Contact information:

Name: *

Company/Clinic: *

Address: *

Address 2:

City/Town: *

State/Province: *

ZIP/Postal Code: *

Country:

Email Address: *

Phone Number: *

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* 2. Website:

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* 3. Role:

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* 4. Who will be sharing assessment results with clients/patients?

Name:

Email:

Name:

Email:

Name:

Email:

Name:

Email:

Name:

Email:

Name:

Email:

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* 5. Treatment and/or services offered (Please check all that apply):

detox

methadone

suboxone

naltrexone

outpatient/IOP

inpatient

residential

individual

group

relationship/family

CBT

MI/MET

DBT

REBT

contingency management

mindfulness

movement

acupuncture

12-step

SMART

celebrate

court diversion

group home

other

Other (please specify)

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* 6. Insurance accepted (Please check all that apply):

state or managed

Medicare or managed

employer

private

permanent disability

none

Other (please specify)

Healthcare/Service Provider Contact Form

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* 1. Contact information:

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* 2. Website:

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* 3. Role:

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* 4. Who will be sharing assessment results with clients/patients?

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* 5. Treatment and/or services offered (Please check all that apply):

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* 6. Insurance accepted (Please check all that apply):

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* 7. Estimated number of monthly intakes:

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* 8. If there are other's you'd like to add, please do so here.

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* 9. Questions or comments?