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In the last 30 days you have experienced
Have you used any substance within the last 30 days? If yes, please provide the name of the substance
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What substances have you used in the past? *Required
Have you ever received inpatient or outpatient rehab services
What services are you in need of?
Have you received or managed your mental health in the past?
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I declared the infomation I have provided is accurate and complete. I understsnd this is an application for services with financial obligation. I am applying for services and will be notified of all possible payment options to include my insurance company, government assistance, if possible and scholarship funding.

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