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Thank you for your interest in our program!

To refer a patient, please complete the form below or call us at 844-292-7372. We look forward to working with you!

We need to know a little bit more to get started.

Want to speak to someone right now?
Help is just a phone call away! (844) 292-7372

Who are you seeking treatment for? *

Name *

Your Name *

Patient's Name *

Name *

First

Last

Patient's Home Address *

Address Line 1

City

State

Zip Code

Email *

Phone *

Your Address *

Address Line 1

City

State

Zip Code

State *

Relationship to Patient

Your Name *

First

Last

Your Phone *

Your Email *

Don't want to fill out this form?
Speak to an Aware Recovery Specialist now! (844) 292-7372

Relationship to Loved One

Does your loved one know you're reaching out to us? *

What services are you interested in?

In-Home Addiction Treatment
Virtual Detox
Medication Assisted Treatment
Not sure

Reason for referral

What was the date you last used your substance of choice?

Are you currently using a controlled medication to support your recovery?

Don't want to fill out this form?
Speak to an Aware Recovery Specialist now! (844) 292-7372

Do you currently have health insurance? *

Does your loved one currently have health insurance? *

Insurance Carrier *

Member ID# / Policy Number

Date of Birth

Patient's Insurance Type

Other Insurance *

How did you hear about us? *

Who referred you to us?

Please tell us the name of the treatment center, hospital, doctor, therapist, or sober house that referred you to us.

Reason for seeking treatment *

How ready are you to begin your recovery journey?

Indicate the next steps for this referral *

Submitting this form does not create a client-provider relationship. This form is for general inquiries only. Please do not submit confidential health information. An Aware staff member will contact you to discuss next steps.

Thank you for your referral! We will be in touch soon.

Thank you for your interest in our program!

We need to know a little bit more to get started.

Don't want to fill out this form? Speak to an Aware Recovery Specialist now! (844) 292-7372

Don't want to fill out this form? Speak to an Aware Recovery Specialist now! (844) 292-7372

Don't want to fill out this form?
Speak to an Aware Recovery Specialist now! (844) 292-7372

Don't want to fill out this form?
Speak to an Aware Recovery Specialist now! (844) 292-7372