Request to Assess
Full Name
*
Telephone Number
*
Email Address
*
What city are you located in?
*
Person Attending Treatment
*
Relationship
*
Addiction or Substance they are using
*
What features are important when finding a treatment centre?
*
Rows
Click all that apply
Medically Supervised Detox
Medication Assisted Detox
Medical team on-site
Mental Health Assessment
Psychotherapist team and clinical staff
12 step methodology
Property and ammenities
Non religious
One on one therapy
Location
Price
After care
Insurance Coverage
Device Allowed, Communication Flexibility
Gender specified
Family involvement
Transport
Are they willing to attend Treatment?
*
Yes
No
Are you looking for a PRIVATE addiction treatment centre in Ontario?
Yes
No
I understand that private addiction treatment is not government funded, and will require a fee.
Yes
No
Save
Submit
Should be Empty: