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.
Verify that your phone number and e-mail are correct!(Required)
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"
Credit Card(Required)
American Express
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Expiration Date