Just tell us a little about yourself. We’ll get in touch to take care of the rest. utm_id utm_source utm_medium utm_campaign utm_term utm_content campaign_url timezone referrer We know the first step is the hardest one to take. Once you’ve made the brave decision to change your life, we make the rest as easy as possible.Call us at 323-522-2218 or take a minute to answer a few questions below. Let’s get your recovery started. Name * First Name Last Name Cell Phone Number * Please enter a valid phone number. Email * example@example.com Date of birth * - Month - Day Year Date Where do you live? * Please Select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming What substance do you need the most help managing? * Alcohol Meth Crack Rx stimulants/ADHD meds Cocaine Are you 18 or older? Yes No Do you have health insurance? Yes No Not sure Who is your insurance provider? * Terms of use * I agree to Affect's terms of use and privacy policies and to receive phone calls, text messages, and emails from Affect. Submit Should be Empty:
