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Your Name:

Zip Code:
Phone Number:

Your Relationship to the Alcoholic/Addict:

Current drug(s) they’re using:

Zip Code in which they live:

Check if able to travel outside of this area code for treatment?:

Please fill in other patient details regarding addict:

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Where do calls go?

Calls to numbers on a specific treatment center listing will be routed to that treatment center. Additional calls will also be forwarded and returned by a quality treatment center within the USA, which includes Right Path Rehab

Calls to any general helpline (non-facility specific 1-8XX numbers) for your visit will be answered by a licensed drug and alcohol rehab facility, a paid advertiser on PalmPartners.com.

All calls are private and confidential.

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