Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *FirstLastEmail *Phone Number *Date of Birth *What insurance coverage do you currently have? * care in have Have you been in treatment? If so, what level of care (detox, residential, IOP, or outpatient)? *Did your previous provider recommend a next level of care, such as PHP or IOP? *What has been going on recently that led you to seek support at this time? *Are you currently using substances? If so, when was your last use? *Are you experiencing any mental health concerns such as anxiety, depression, or mood changes? *Are you currently medically stable, or have you needed detox services recently? *What does your current living environment look like? Is it supportive of recovery? *Are you available to participate in a structured program during the day (typically 4–6 hours per day)? *Do you have any barriers to attending treatment regularly (transportation, work schedule, childcare, etc.)? *Do you have any questions or concerns about the PHP program? *Submit Call now for a Free Consultation (360) 676 -4485 Thank you for submitting your application
