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Healthcare/Service Provider Contact Form
Welcome. We’re very excited to work with you.
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1.
Contact information:
(Required.)
Name:
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Company/Clinic:
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Address:
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Address 2:
City/Town:
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State/Province:
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AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code:
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Country:
Email Address:
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Phone Number:
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2.
Website:
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3.
Role:
(Required.)
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4.
Who will be sharing assessment results with clients/patients?
(Required.)
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):
(Required.)
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):
(Required.)
state or managed
Medicare or managed
employer
private
VA
permanent disability
none
Other (please specify)
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7.
Estimated number of monthly intakes:
(Required.)
8.
If there are other's you'd like to add, please do so here.
9.
Questions or comments?
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