I WANT TO STOP NOW - Addiction Treatment.  Continuing Care.  Referral Network.
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Alcohol Abuse Treatment Program
Alcohol Detox Treatment Center
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Addiction Treatment.  Continuing Care.  Referral Network.
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Join Our Referral Network

Medical professionals database registration form, required fields.

To be listed in the I Want To Stop Now national referral network of addiction certified medical professionals, please complete the following information and submit this form.

 
Professional focus*
Physician: Internist
Physician: General practitioner
Physician: psychiatrist
therapist
interventionist
First Name*
Middle initial
Last Name*
credentials*
ASAM certified?*
Yes
No
Licensed/certified addiction counselor?*
Yes
No
Organization*
Years in practice*
Years of specialization in alcohol abuse*
Qualifications*
Briefly describe your philosophy on the treatment of alcohol addiction*
Is your philosophy based on the 12-Step approach?*
Yes
No
Street Address 1*
Street Address 2
City*
State/Canadian Province*

  -or- Non-US/Canadian Province/Shire/Region:
Country*
Zip Code
Office Phone
Home Phone
Fax Number
Website
Specialty areas
Alcohol addiction
Opiate addiction
Addiction related pharmacology
Rational Emotive Behavioral Therapy
Cognitive behavioral therapy
Psychotherapy
Modality focus
Individual
Group
Family
Marriage
Children
Delivery mode
Outpatient
Day programs
Inpatient/hospital
Residential
Halfway house
Extended care
Acute-care
Range of fees*
Payment methods accepted*
Insurance
Private pay
Do you agree to the terms of use?*
Yes
No
  (*required)
 
 

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