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Please fill out this form if you are in need of placement into an addiction treatment program, detox center, or need help locating inpatient drug or alcohol rehab programs in your area. By filling out this form, you are giving consent to having a counselor contact you, by phone or email, to assist with addiction issues. 100% Confidential. NOTE: You can speak immediately with any of our counselors 24 hours a day, 7 days a week by calling 1-800-513-5423

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