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Name

Address

Email Address

Phone Number

Addiction

How many years has this been an issue for you?

Desired length of treatment

Preferred Rehab Facility?

Preferred start date of treatment

Do you require a medical detox?

Yes No

Have you stayed in a rehab facility before?

Yes No

Do you wish to engage with a 12 step program

Yes No

Gender

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Age?

Any more information or preferences?

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hello@ethicalrehabs.com