Your Name (required)

Name of Person Needing Services (required)

Your relationship to the person:

 Self Child Friend Spouse Parent Sibling Treatment Professional/Therapist

Please describe a brief description of the situation

Personal Data of Person Needing Help

Drug of Choice (check all that apply)

 Alcohol  Marijuana  Inhalants  Cocaine Powder  Crack  Barbiturates (Phenobarbital, etc.)  Benzodiazepines (Xanax, Valium, etc.)  GHB  Steroids  Methadone  Suboxone  Methamphetamines (Crystal Meth)  Ecstasy  Ketamine (Special K)  PCP  LSD  Heroin  Prescription Drugs  Narcotic Pain Relievers (Oxycontin, Hydrocodone, etc.)  Stimulants (Ritalin, Adderoll, Concerta) Other

Method of Use

 Ingesting/Swallowing  Snorting  Inhaling/Sniffing  Smoking  Injecting (I.V.)  Other

What kind of help are you looking for? (Check all that apply.)

 Private Therapist  Psychiatrist Detox  Outpatient Treatment  Sober Living House  30-day Treatment Center  90-day Treatment Center  Long-term Treatment Center  Extended Care  Adolescent/Young  Adult Older  Adult Psychiatric Hospital  Sober Escort /Sober Companion  Workshop Behavioral Treatment  Therapeutic Boarding School  Health Spa/Recovery Retreat  Recovery Coach  Eating Disorder Treatment  Sex & Love Addiction Treatment  Gambling / Shopping Treatment  Hoarding Treatment  Video Game Addiction Treatment  Co-Dependency Treatment  Couples Treatment  Wilderness Program  Intervention  Monitoring Service  Christian  Other

Gender Specific?

 Yes No

Dual Diagnosis?

 Yes No

Is location of treatment important?

 Yes No

Please list any co-occurring disorders/dual diagnosis:

Specific Requests (i.e., pets, computers, gym, other amenities):

Financial Resources

Insurance?

 Yes No

Type of Insurance:

Private Pay

 None available  Limited resources available  Flexible resources available

Other:

California Addiction Help is dedicated to getting you the most cost-effective treatment available for your needs – we have pre-arranged financial agreements with many service providers. This allows us to get the help you want and need at a lower cost.

Most form submissions will be responded to within minutes. Please provide detailed and accurate information for best results.

Primary Phone

Secondary Phone

Your Email (required)

Please be advised that filling out this form, accessing this website as well as email and call inquiries regarding treatment, and or potential treatment, does not constitute the formation of a clinical and or professional relationship.