Confidential Intake

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The more you share, the better we can match you to the right treatment. Every field is private and reviewed only by our team. Skip anything you're not ready to answer.

100% Confidential Free Service 24h Response

If this is an emergency or you are in crisis, please call or text 988 (Suicide & Crisis Lifeline) or 1-800-662-HELP (SAMHSA, 24/7). This form is for matching to non-emergency treatment.

1. Who is filling this out?

So we know who we're speaking with.

MyselfA loved one

Your full name *

Email *

Phone *

Preferred contact method

Best time to reach you

2. About the patient (you)

Just enough so we can find appropriate options.

First name *

Age *

Gender (optional)

City & state *

Willing to travel for treatment?

Local onlyWithin my regionAnywhere in the U.S.

3. What you're dealing with

Be as candid as you're comfortable with — it stays private.

Primary concern *

Substances involved (check all that apply)

AlcoholOpioids / HeroinPrescription painkillersBenzodiazepines (Xanax, Klonopin, etc.)CocaineMethamphetamineCannabis / MarijuanaNicotine / VapingPrescription stimulants (Adderall, etc.)Sleep medicationsOther

Behavioral concerns (check all that apply)

GamblingGaming / InternetSex / PornographyShoppingFood / EatingRelationships / Codependency

How long has this been going on?

When was last use?

Typical daily amount / frequency

4. Mental health & medical

Co-occurring conditions are common and important for matching.

Diagnosed or suspected mental health conditions

DepressionAnxietyPTSD / TraumaBipolar disorderADHDEating disorderSchizophrenia / PsychosisPersonality disorderOther

Current medications (optional)

Thoughts of suicide or self-harm

If you're in immediate danger, please call 988 right away.

Other medical conditions (optional)

5. Treatment history

Have you (or the patient) received treatment before?

What's worked or not worked? (optional)

6. Practical considerations

So we don't waste your time on options that won't fit.

Insurance provider (optional)

Budget situation

Treatment types you're interested in (check all that apply)

Medical detoxInpatient / ResidentialPartial hospitalization (PHP)Intensive outpatient (IOP)Outpatient therapyMedication-assisted treatment (MAT)Ketamine-assisted therapyTMSEMDR / Trauma therapyDual diagnosis programFamily therapySober livingNot sure — please advise

How urgently do you need help?

7. Goals & anything else

What does success look like for you?

Anything else we should know?

I understand Advanced Recovery Treatments is a free educational and matching service, not a medical provider, and I consent to being contacted about treatment options. My information will be kept confidential.

Confidential — never shared without your permission.