Please fill out the form below to the best of your ability and we will contact you shortly.

  • Parent/Guardian Information

    This is the information of the person who is requesting help for their loved one.
  • Child (person in need of services) Information

  • Enter the drug(s) which the affected person is addicted. Hold the ctrl key to select multiple drugs.
  • Select the type of insurance of the PoC
  • Additional Information

  • Please click the button below to submit the information and we will contact you as soon as possible to discuss our services and fees.