Contact Us

Drug Rehab Canada - Confidential Callback Form

Thank you for your interest in our drug addiction treatment services and alcohol rehabilitation services. Fill out this confidential form and one of our Rehab Placement Specialists will call you back at your convenience. The information gathered is used only to help us locate the ideal program and facility to meet your specific needs.

Generated with MOOJ Proforms
Name:
Phone:
Best time to call:
Email:
 
Addicts name:
 
City:
State/Prov:
Country:
 
Relationship to addict:
 
Nature of problem:
Alcohol
Drugs
Other
Has the addict ever received treatment for their addiction?
Yes
No
If yes, what kind of treatment?
Did they complete the treatment?
Yes
No
Has the addict ever received any treatment by a Psychiatrist, Psychologist or been Diagnosed with a mental illness?
Yes
No
Is the addict currently / has ever been on any prescribed medication of a mood altering or Narcotic nature?
Yes
No
Does the addict have any chronic illness? Please Specify:
Other specific health requirements which could affect treatment:
Additional Information:

Call Me Now

Request Immediate Call Back
Stop Addiction Today!
Phone:
-
Thank You

For more information regarding drug addiction, alcohol addiction or our addiction treatment services in North America, please contact us today.

addiction-enders-logo