Registration Form

Home
About Us
Services
Financial Information
News and Events

I'M LOOKING FOR :

Addiction Help

Mental Health

Counseling Services

Get Started Here

Full Name

Phone

Date of birth

Street Address

City

State

Insurance Provider

Insurance Member ID

Referred By

Seeking Support For (check all that apply):

Alcohol Use

Benzodiazepine Use

Other Drug Use

Gambling

PTSD

Depression/Bipolar

Suicidal Thoughts/attempts-within past month

Suicidal Thoughts/attempts-history

Anxiety

Chronic Pain

Other

Housing Status

Choose One

Housed
Unhoused
No elements found. Consider changing the search query.
List is empty.

Employment Status

Choose One

Employed/working full time
Employed/not working/working part time
Unemployed/not working
No elements found. Consider changing the search query.
List is empty.

Is there any other information we should know to better assist you?

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.

Please note that by submitting this form via this web portal, you acknowledge and accept the risk of communicating your PHI via this unencrypted system and wish to continue despite fully understanding those risks. By clicking"submit:, you agree to hold Roman Marketing, Balanced Recovery Center, and godaddy.com harmless for unintended use, disclosure, or access to this PHI.