Request a Consultation Home» Consultation» Request a Consultation Fill out the form below and one of our addiction experts will be in touch as soon as possible. We take privacy seriously, the form is sent using an encrypted connection. Contact InformationFirst NameLast NameEmail PhonePatient InfoFirst NameLast NameClient DOBSubscriber First NameSubscriber Last NameSubscriber DOBSSN (Last 4)Insurance InfoInsurance ProvidersInsurance Policy #Group NumberInsurance Provider Phone NumberAdditional Notes