A.W.A.R.E.

A Women's Active Recovery Enterprise

Request an Intake Appointment
 

An intake coordinator will contact you to schedule an appointment when your information is received. 

First Name
Last Name
Date of Birth
Age
Address Line 1
Address Line 2
City
State
Zip Code
County
Daytime Phone() -
Cell Phone() -
Reason Seeking Treatment
Referral Sournce
Referral's Telephone Number() -
Date of Last Use
Primary Substance
How much money do you spend on your primary drug of choice daily?
Secondary Substance
How much money do you spend on your secondary drug of choice daily?
Additional Substances
Do you have any previous mental health diagnosis?
Do you have any medical conditions?
Are you currently taking any medications? Which ones?
Are you currently pregnant?







7801 York Road
Suite 203
Towson, Maryland 21204

awarecounseling.org, A.W.A.R.E., 2007

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