Due to the influx of applications, we are currently not accepting applications for financial assistance. Please see our resources available or contact us for questions regarding treatment and placement.

What are your goals? *

If yes, what insurance type?

Name: *

Do you have children? *

Yes

No

Have you ever been to treatment? *

Yes

No

If yes, who has custody/guardianship?

Email: *

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How can we help? *

If need be, are you willing to relocate temporarily and/or go to sober living? *

Yes

No

Please submit a state case worker's information if currently in treatment.

Thank you for contacting us! If needed, you will hear back within 48-72 hours.

Where are you currently residing (detox, holding, home, etc.) *

Date of Birth *

Marital status: *

Single

Married

Divorced

Widowed

Dennis Messing Memorial Foundation.