Thank you so much for your interest. Please fill out the following form so we can pair you with the treatment team best suited for your needs.

Client Name:

Date of Birth:

Address:

Phone Number:

We will call you to create your profile and schedule your initial appointment, what is the best time to reach you:

Email Address:

Insurance:

We accept several commercial insurances. During our call we will inform you if your insurance is accepted. If we do not accept your insurance, we will provide you with the cash pay cost before scheduling your initial appointment. Our substance use groups and toxicology screens are part of our monthly membership plan and are currently cash only.

Are you currently in treatment at another facility?
YesNo

If so, where and what services are you receiving?

Please tell us how we can help you by briefly listing your reason for requesting an appointment:

Where did you first hear about Revitalize Wellness and what led to your decision to request an appointment? We would love to hear if someone recommended our services.

Is there a member of the team you would prefer to see? If so, please tell us why. Your response will be a top factor as we pair you with the most appropriate member of the team.

Thank you for completing the form. A member of our team will contact you within 24 hours for your consultation. Our goal is to offer your initial appointment within 24 hours from this consultation call.