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OP: Outpatient Rehab San Diego
IOP: Intensive Outpatient Program San Diego
PHP: Partial Hospitalization Treatment Program San Diego
Sober Collective
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619-542-9542
Outpatient Drug Rehab Near Me
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Name
*
First
Last
Who Are You Looking To Help?
*
Loved One
Myself
What Is Your Loved One's Name?
*
First
Last
How Do You Feel About Recovery?
Hesitant
Moderate
I Am Ready For Change
How Do They Feel About Recovery?
Hesitant
Moderate
It's Time For Change
I Don't Know
Substances Used (check all that apply)
Select All
Alcohol
Cocaine
Meth
Weed
Heroin
Crack
Ecstasy
Ketamine
Other
Substances Used (check all that apply)
Select All
Unsure
Alcohol
Cocaine
Meth
Weed
Heroin
Crack
Ecstasy
Ketamine
Other
How Have Drugs Affected Your Life? (select 1 or more)
Select All
Career & Personal Life: Lost your job, a special someone, your home, etc.
Physical Health: Weak body, organ failure, unhealthy eating habits, etc.
Mental Health: Feeling hopeless and depressed, dealing with anxiety, etc.
How Have Drugs Affected Your Loved One's Life? (select 1 or more)
Select All
Career & Personal Life: Lost your job, a special someone, your home, etc.
Physical Health: Weak body, organ failure, unhealthy eating habits, etc.
Mental Health: Feeling hopeless and depressed, dealing with anxiety, etc.
Do You Have Insurance?
No
Yes
Does Your Loved One Have Insurance?
No
Yes
Unsure
Email
*
Phone
*
Insurance Provider
Insurance ID
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