Contact | AIR

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.
Name*
First Last
Phone*
Email*
Relationship to Person of Concern (PoC)*
Initial Concern. Why are you reaching out to AIR for assistance?*
Is the addict aware you are reaching out?*
Child (person in need of services) Information
Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Drug(s) of Choice*
Enter the drug(s) which the affected person is addicted. Hold the ctrl key to select multiple drugs.
Type of Insurance*
Select the type of insurance of the PoC
PoC's level of motivation for treatment? 1 being unmotivated and 10 being highly motivated*
Have they been in rehab before?*
If so, when and where?*
Additional Information
Other comments or information you would like AIR to know prior to your consultation.*
Who Referred you to AIR?
Please click the button below to submit the information and we will contact you as soon as possible to discuss our services and fees.
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Parent/Guardian Information