Drug & Alcohol Rehabilitation Assistance

If you are in immediate danger or experiencing a medical emergency, call 911 right away. This form is not monitored for emergencies.

If you need immediate help finding treatment, call SAMHSA’s National Helpline at 1-800-662-HELP (4357)

First name

Last name

Are you over the age of 18?

Phone

Which substance is causing you the most trouble?

How often do you use?

Do you have any current medical conditions we should know about?

Are you prescribed any medication? If so, what?

Have you ever been diagnosed with depression, anxiety, PTSD, bipolar disorder, or another mental health condition?

Have you ever been to detox, rehab, sober living, or outpatient treatment before? If yes, when and where?

Did you complete the program?

Do you currently have health insurance?

If yes, what type: Medicaid, Medicare or Private Insurance?

Are you employed right now?

Emergency Contact Name and your relationship to this person.

Emergency Contact Number

If accepted, do you have an animal that would need to be taken care of?

Share with us your story.