Apply here to get the help you need.

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.