| name |
|
| phone number |
|
| your e-mail address |
|
please re-verify exact
e-mail address
|
|
| this request is for |
myself
family member
friend |
| at this point, are they ready and willing to go to rehab? |
yes
no
maybe |
| geographic location for listings of treatment centers |
| city or cities |
|
| state or states |
|
| zipcode |
|
| willing to consider other possible options / locations |
yes
no
maybe |
| level of care |
Detox
Inpatient (full time)
Outpatient (part time)
Not sure
|
| person's age group |
Adult – 24 and over
Young Adult – 18 to 24
Adolescent – 17 and under
|
| dependency issues |
Alcohol
Drugs
Medications
Other
|
| mood disorders |
Depression
Anger
Bi-polar
Anxiety
ADD/ADHD
Other
|
| insurance coverage |
Medicaid
Medicare
Any Type of Private Health Insurance
U.S. Military
State-financed (Tenncare, Medical, etc.)
Other
None
|
| If necessary , how much out-of-pocket funding might be available for private rehab ? |
None
$1-$2,500
$2,500-$7,500
More than $7,500
Not sure
|
| If necessary, is it ok to call you |
Yes
No
|
| If yes, is it ok to leave a message |
Yes
No
Not Applicable
|
| additional facts and background information you feel is pertinent |
NOTE: All information is protected by HIPPA (Health Insurance Portability and Accountability Act of 1996) regulations. |
|
to protect your information |
|
| |
|
