Rotary Recovery LLC

3100 Dundee Rd. Suite 502 Northbrook IL 60062

Who are you seeking support for? *

For myself

For my spouse/partner

For my child

For another family member

For my Friend or Colleague

What type of addiction or behavior is causing concern right now? *

Alcohol

Substance Abuse

Mental Health

(You may choose more than one)

Has treatment been attempted before? *

This would be the first time

Outpatient

Detox under medical supervision

Residential rehab - Inpatient

Multiple past attempts

Currently in treatment

How urgent does the situation feel right now? *

Immediate help needed (today/ASAP)

Within the next few days

Within the next week

What insurance provider do you have? (If known) *

Example: Medicaid, Aetna, Cigna, Blue Cross Blue Shield . We also accept direct payment.

What is your Zip code? (this helps us know that we are reaching people in our area) *

What is your Full Name? *

Date of birth? *

What is your best phone number? *

What is your best email address? *

I agree to the terms & conditions provided by Rotary Recovery LLC, and by providing my phone number, I agree to receive text messages from Aviv Recovery.