ASAM Treatment

ASAM Treatment Enrollment Form

Use the form below to register for the ASAM Treatment program.

Tele-health Services

Most of our services are available to be completed remotely via a telehealth session. Tele-health appointments can be completed with most devices that have a camera and microphone, including a laptop computer, Android phone, Apple iPhone and most tablets.

Appointment Information

Enter the information below as it would appear on your Driver's License or State Issued Photo ID. If you have a DDS Identification Card, the ID Number is the same as your License Number.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone(Required)

Email(Required)

Verify that your phone number and e-mail are correct!(Required)

I understand I will receive a phone call or e-mail to set my appointment time & have verified my phone number is correct.

License/Photo ID Upload

Attach a copy of your photo ID below or e-mail it directly to [email protected]. You can scan in your ID or take a clear photo with your smartphone camera.

Max. file size: 50 MB.

Select Your Program Length(Required)

ASAM I 6-12 Week Programs have a set cost of $450. If you are in need of a 17 week or longer course, please select the "17 Weeks or More"

ASAM I 6-12 Weeks $450.00 Complete Program

ASAM I 17 Weeks or More: $450.00 Deposit (Total Cost Based on Program Length)

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

CAPTCHA

PROVIDING
PEOPLE WITH HELP

ASAM Treatment Enrollment Form

Tele-health Services

Appointment Information

Registration Forms

PROVIDING PEOPLE WITH HELP

ASAM Treatment

ASAM Treatment Enrollment Form

Tele-health Services

Appointment Information

Registration Forms

PROVIDING
PEOPLE WITH HELP