Your relationship to this person
Self Spouse Treatment professional/Therapist Child Parent Sibling Friend Other
Personal data of individual needing help
Male Female
Drug of Choice (check all that apply)
Alcohol Marijuana Inhalants Cocaine Powder Crack Barbiturates (Phenobarbital, etc.) Benzodiazepines (Xanax, Valium, etc.) GHB Steroids Methadone Suboxone Methamphetamines (Crystal Meth) Ecstasy Ketamine (Special K) PCP LSD Heroin Prescription Drugs Narcotic Pain Relievers (Oxycontin, Hydrocodone, etc.) Stimulants (Ritalin, Adderoll, Concerta) Other
Method of Drug Use
Ingesting/Swallowing Snorting Inhaling/Sniffing Smoking Injecting (I.V.) Other
What type of help are you looking for (check all that apply)?
Private Therapist Psychiatrist Detox Outpatient Treatment Sober Living House 30-day Treatment Center 90-day Treatment Center Long-term Treatment Center Extended Care Adolescent/Young Adult Older Adult Psychiatric Hospital Sober Escort /Sober Companion Workshop Behavioral Treatment Therapeutic Boarding School Health Spa/Recovery Retreat Recovery Coach Eating Disorder Treatment Sex & Love Addiction Treatment Gambling / Shopping Treatment Hoarding Treatment Video Game Addiction Treatment Co-Dependency Treatment Couples Treatment Wilderness Program Intervention Monitoring Service Christian Other
Yes No Yes No Yes No
Yes No
Financial Resources
The Way Out is dedicated to getting you the most cost-effective treatment available for your needs – we have pre-arranged financial
agreements with many service providers. This allows us to get the help you want and need at a lower cost.
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Please be advised that filling out this form, accessing this website as well as email and call inquiries regarding
treatment, and or potential treatment, does not constitute the formation of a clinical and or professional relationship.
