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
Is location of treatment important?
Please list any co-occurring disorders/dual diagnosis:
Specific Requests (i.e., pets, computers, gym, other amenities):
Type of Insurance:
None available Limited resources available Flexible resources available
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.
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.