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What substance are you seeking help for?

Do you currently have private health insurance in the United States?

Where did you get your health insurance?

What type of insurance do you currently have?

Would you be able to provide a picture of your insurance information on this form?

Please upload a clear picture of the front of your insurance card

Drop your file here or click
Accepts png, jpeg, pdf

Please upload a clear picture of the back of your insurance card

Drop your file here or click
Accepts png, jpeg, pdf

How would you like us to reach out?

What is your gender?

What is your date of birth?

Please select a date.

What is your contact information?

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What is your phone number?

Thank You

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