Contact Us Contact UsUse the form below to contact our team and schedule an assessment today!Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Name *Email *PhonePhone *Preferred Contact MethodEmailPhoneWhat are you contacting us about today? *Select OneAdmissionsRecords Request/Reporting ConcernsProvider ReferralsHuman ResourcesDonationsCommunity RelationsOtherWhat substance(s) are you using?Date of last substance use:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920What substance(s) is your referral regarding?Date of last substance use:MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Comment or Message *How did you find out about us? *Select OneFamily / FriendGoogle/Internet SearchTelevision AdvertismentReferralWho referred you? *Lane County HealthLane County JailLane County Parole and ProbationSponsorsMedical providerDHSRelief NurseryOtherPlease write your referral in the box belowSUBMIT
