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Information Request

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  • Chemical Dependency Programs for Teens
  • Chemical Dependency Programs for Adults
  • Family Programs, Support, and Interventions
  • Eating Disorders Programs
    •  
    Please mail me information on the following topics:
         
      (Unity Chemical Dependency is not identified on the envelope)

    Chemical Dependency Programs for Teens
    Chemical Dependency Programs for Adults
    Family Programs, Support, and Interventions
    Eating Disorders Programs
       
      * indicates required information.
      *First Name:
      *Last Name:
      *Address (line 1):
      Address (line 2):
      *City:
      *State:
      *Zip:
         
    Please call me to schedule a confidential chemical dependency evaluation.
         
      * indicates required information.
      *Phone Number:
    (Unity Chemical Dependency appears as “unknown” on Caller ID.)
      *Contact Name:
      *Best time to contact me:
        Morning (8:00-11:30 a.m.)
    Lunch time (11:30 a.m. – 1:30 p.m.)
    Afternoon (1:30 – 4:30 p.m.)
      *If you are not available when we call, please indicate if you would like us to leave a message:
        Yes, please leave a message
    No, please do not leave a message
         
      View list of information I will need to schedule an evaluation