877-77-DETOX

DETOX PROGRAMS SCREENING FORM

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Current PCP or Specialist Name:
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Current Daily Opiate Use:
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(when and how long was abstinence?)
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Overdoses(how many):
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Past Medical History:
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Congratulations on your decision to contact us... we appreciate your interest in our treatment programs!

We look forward to providing you with more information and answering all of your questions.

You can expect a response from Jennifer, our Clinical Supervisor, within the next 24 hours.

If you would like speak with Jennifer sooner, please call 1-877-77 DETOX (33889)

Again, thank you for contacting The Coleman Institute.

"When your mind says give up, hope whispers one more try."
Anonymous

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