We want to make the admissions process as stress-free and easy for you (or your family member) as possible. Call us at 480-408-5923 for a confidential consultation to go over the program details and finance details to determine what is the best fit for your needs.
Help for a family member:
Please click on the button below to complete the form which best allows us to help your family member in need.

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Request for Help: Alcohol and Drug Addiction Support

Personal Information of the Requester (Your Information) :

Relationship to the Family Member:

Phone Number:

Email:

Preferred Contact Method:

Best Time to Contact You:

Information About The Family Member

Full Name of Family Member:

Age:

Gender:

Primary Substance(s) of Concern:

How long has the addiction been a problem?

Is the individual currently seeking treatment?

Has the family member previously received treatment for addiction?

Has the individual experienced any of the following? (Check all that apply)

Current Situation:

Is the family member open to treatment or recovery programs?

Does the individual have a support system (family, friends, etc.)?

Does the family member live in a safe and supportive environment?

Do you believe immediate intervention is necessary?

Request Details:

What specific help or support are you seeking for your family member?(Check all that apply)

Is there anything else you'd like us to know about the family member's situation? (Optional)

Consent & Confidentiality Agreement:

By submitting this form, you consent to sharing the provided information with the relevant support or treatment professionals. All information will be kept confidential and will only be used for the purpose of assisting in your request.

I consent to the collection and use of this information for treatment referral

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SUBMIT