Call
888-661-4075
and get help today!
Centers.com
Home
Addiction Treatment
Treatment Program Guide
Types of Treatment Programs
Support
Consultation
Please complete the form below and someone will be in touch with you shortly.
Please Enter Your Contact Information
Your First Name:
*
Your Last Name:
*
Your Email Address:
Your Phone Number:
Use This Format Only: (###) ###-####
Please Describe The Individual Needing Treatment
Who Is the Treatment For?
*
Select...
Self
Family Member
Friend
Other
Name Of The Person Seeking Treatment:
*
Does This Person Want Help?
*
Select...
Yes
No
Not Sure
Does This Person Have Insurance?
*
Select...
No
Yes - PPO
Yes - Fee for Service
Yes - HMO
Yes - POS
Yes - Medicare/Medicaid
Yes - Tricare/Other Military
Yes - Other
If Necessary, How Much Out-Of-Pocket Money Is Available for Private Rehab?
Select...
None
$1 - $5,000
$5,000 - $10,000
$10,000 - $20,000
$20,000 - $30,000
$30,000 - $40,000
$40,000 - $50,000
More than $50,000
Message to Treatment Center:
Phone
This field is for validation purposes and should be left unchanged.
