There are no charges associated with our placement services. Your Name* Name of person needing treatment* Your relationship to this personYour relationship to this personSelfSpouseChildParentSiblingFriendTreatment professional/TherapistPlease provide a brief description of the current situation: Personal data of individual needing helpGenderMaleFemaleAgeCurrent City/StateMarital StatusMarriedSingleDivorcedSeparatedWidowedChildrenYesNoNicotine useYesNoChronic medical issuesYesNoPending legal issuesYesNoDrug of Choice (check all that apply) Alcohol Cocaine Powder Benzodiazepines (Xanax, Valium, etc.) Methamphetamines (Crystal Meth) PCP Prescription Drugs Marijuana Crack GHB Methadone Ecstasy LSD Narcotic Pain Relievers (Oxycontin, Hydrocodone, etc.) Inhalants Barbiturates (Phenobarbital, etc.) Steroids Suboxone Ketamine (Special K) Heroin Stimulants (Ritalin, Adderoll, Concerta) Other What type of help are you looking for (check all that apply)? Private Therapist Outpatient Treatment 90-day Treatment Center Adolescent/Young Adult Sober Escort /Sober Companion Therapeutic Boarding School Eating Disorder Treatment Hoarding Treatment Couples Treatment Monitoring Service Psychiatrist Sober Living House Long-term Treatment Center Older Adult Workshop Health Spa/Recovery Retreat Sex & Love Addiction Treatment Video Game Addiction Treatment Wilderness Program Christian Detox 30-day Treatment Center Extended Care Psychiatric Hospital Behavioral Treatment Recovery Coach Gambling / Shopping Treatment Co-Dependency Treatment Intervention Other Method of Drug Use Ingesting/Swallowing Smoking Snorting Injecting (I.V.) Inhaling/Sniffing Other Gender specificYesNoDual diagnosisYesNoChronic relapseYesNoIs location of treatment important?YesNoPlease list any co-occurring disorders/dual diagnosisSpecific Requests (i.e., pets, computers, gym, other amenities)Financial ResourcesInsuranceYesNoType of InsurancePrivate Pay (most insurance companies do not cover the entire cost of treatment)None availableLimited resources availableFlexible resources availableThe 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. Most form submissions will be responded to within minutes. Please provide detailed and accurate information for best results.Primary PhoneSecondary PhoneEmail* 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.