Phoenix Transformative

1

How did you hear about Phoenix Transformative?* This field is required.Who referred you?

2

Full Name* This field is required.

3

Phone Number* This field is required.

4

Email Address* This field is required.

5

What is your relationship to the client?* This field is required.

6

Client Age?* This field is required.

7

Client Location?* This field is required.

8

What prompted you to reach out today?* This field is required.

9

Please briefly describe the current challenges and goals for support. * This field is required.

10

What date do you need support to begin?* This field is required.

Date

11

Is the client currently in Detox, Residential Treatment or Supportive Living?* This field is required.

YESNO

12

What level of support are you seeking?* This field is required.

Check-In Support (1–2 hrs) — $500

Half-Day Support (4–6 hrs) — $800

Extended Day Support (6–8 hrs) — $1,200

Full-Day / 24-Hour Support — $2,000

13

Are you seeking 24 hour in-person support?* This field is required.

YESNO

14

What level of 24 hour in-person support are you seeking?* This field is required.

Daily Support — $2,500

Weekly Engagement — $15,000

Monthly Engagement — $60,000

90-Day Commitment — $50,000/month

15

What level of Concierge Support are you seeking?* This field is required.Includes 10 hours of in-person support per week, in addition to 24/7 phone support.

Weekly Engagement — $8,000

Monthly Engagement — $30,000

90-Day Commitment — $25,000/month

16

All services are prepaid in advance and payment is required prior to the start of services. Due to the nature of reserving time, availability, and support capacity, all payments are non-refundable.* This field is required.Please acknowledge:

I understand and acknowledge the payment policy.