For Yourself | Red Oak Recovery

Looking for drug rehab treatment for yourself? Please complete the form below to get in touch with us regarding treatment. If you need immediate assistance, please call Red Oak Recovery^® at 866.457.7590.

Your Contact Information
Your Name*
First Last
Return Callback Phone Number*
Email*
Who is seeking treatment?*
- Yourself
- A Loved One
How Did You Hear About Us?
Loved Ones Information
Your Information
Loved Ones Name*
First Last
Loved Ones Date Of Birth*
Date Format: MM slash DD slash YYYY
Your Date Of Birth*
Date Format: MM slash DD slash YYYY
Additional Information
Insurance Information
Would you like us to verify your or a loved ones insurance benefits?*
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Policy Holders Name*
First Last
Policy Holders Date Of Birth*
Date Format: MM slash DD slash YYYY
Policy Holders Address**
Street Address Address Line 2 City State ZIP Code
Insurance Company's Name*
Insurance Company's Phone Number*
Member ID*
Group Number*
Subscriber relationship to client*
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Your Contact Information

Loved Ones Information

Your Information

Insurance Information

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