For Yourself - Red Oak Recovery<sup>®</sup>

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
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Loved Ones Information
Your Information
Loved Ones Name*
First Last
Loved Ones Date Of Birth*
Your Date Of Birth*
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*
Policy Holders Address**
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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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