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Hope Springs Recovery Center
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Individual Therapy
Group Therapy
Family Therapy
Cognitive Behavioral Therapy (CBT)
Dialectical Behavior Therapy (DBT)
Psychoeducation
Psychiatric Evaluation & Medication Management
24/7 Crisis Coverage
Case Management
Holistic Therapies
Relapse Prevention Planning
Discharge & Transition Planning
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Intake form
Help us serve you better
Name
*
Email address
*
Phone number
What type of treatment are you seeking?
Select
PHP (Partial Hospitalization Program)
IOP (Intensive Outpatient Program)
Both PHP and IOP
Do you have any co-occurring mental health conditions?
Please select at least one option.
Anxiety
Depression
Bipolar Disorder
PTSD
Schizophrenia
None
What substances have you used?
Please select at least one option.
Alcohol
Marijuana
Prescription drugs
Cocaine
Heroin
Methamphetamines
Have you previously attended any treatment programs?
Select
Yes
No
What is your primary goal for treatment?
Do you have PPO insurance?
Select
Yes
No
How did you hear about us?
Select
Referral
Online Search
Social Media
Which service or services are you interested in?
Please select at least one option.
Individual therapy
Group therapy
Family therapy
Additional questions or comments
Submit
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