When contacting The Coleman Institute, your complete privacy is assured, whether your interest in drug or alcohol detoxification is for yourself or someone else. You may tell us how you would like us to return the contact: by e-mail, telephone, regular mail or fax. We will not contact you in ways you have not specifically approved.

By using the e-mail form below, you will send a private message to a trained, discreet Coleman Institute client services professional. We will disclose to no one outside The Coleman Institute that you have contacted us.

Please provide the following contact information:

*Required Fields
	Your name* (you may use an alias) :
	How would you like The Coleman Institute to contact you?*	Choose E-mail Telephone Regular Mail Fax
	If you chose e-mail, provide your e-mail address.
	Would you like to receive our monthly newsletter?	(check if yes)
	If you chose the telephone, provide your telephone number.
	If you chose the fax, provide your fax number.
	Enter the best time of day to phone/fax.
	Include your time zone:
	If you chose regular mail, provide your address:
	City:
	State/Province:
	Zip/Postal Code:
	Are you interested in our services for yourself or another person?*	Choose Self Another
	How old is the potential patient?*	Choose Under 18 18-25 26-35 36-45 46-55 56-65 Over 65
	To what is the potential patient addicted?*	Choose Heroin Methadone Prescription Opiate Painkillers Other
	If you are not the potential patient, what is his/her relationship to you?	Choose Spouse/Significant Other Child Parent Other Family Member Friend Patient Client Employee/Co-Worker Parishoner Other
	How did you learn about The Coleman Institute?	Choose Television Advertisement Radio Advertisement Newspaper/Magazine Ad News Story on TV, in Newspaper or Magazine From a Friend Other
	When you click the submit button, the above information will be transferred to The Coleman Institute. For security purposes, please enter the series of numbers shown above