Schedule A Consultation

The consultation will take approximately 10-15 minutes where you will speak directly with one of our professionally trained care coordinators. The following form is confidential and protected health information under HIPAA and 42 CFR Part 2.

Please complete the form below

Name *
Name
Date of Birth *
Date of Birth
Phone *
Phone
Is it okay for us to call or text you at this number? *
Have you used Suboxone or Buprenorphine before? *
Do you have health insurance? *
I am interested in the following location(s): *