Intake Form | Partnership 4 Recovery

Intake Information

Contact Partnership 4 Recovery to find treatment for yourself or a loved one.

We also offer prayer and support during your journey to recovery.

Maria, our administrator will respond to all inquiries within 24 hours.

Let us help you find the treatment you need.

"Please note that any and all information is kept in private and is not shared*

There is no right or wrong answer, these questions are geared towards finding the right assistance for your specific situation.

Full Name *

E-mail *

Contact number *

DOB *

How long in addiction? *

DOC ( Drug of Choice) *

Where are you located? *

Do you have any health problems? *

Please list any medication you're taking *

Are you on disibility? *

Are you pregnant? *

Do you have insurance? *

Are you capable of working? *

Do you have any pending charges? ( List charge and county ) *

Are you on probation or parole? ( Please list county ) *

Are you of sex offender status? *

Next of kin emergency contact *

Name of person referring you to us *

Message *

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