Request Appointment

Complete the brief form below and someone from our admissions team will contact you within one business day to review options, verify insurance, and schedule an appointment.

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First Name *

Last Name

Phone Number

Email *

Birth MonthJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Birth Day12345678910111213141516171819202122232425262728293031

Information Type

Birth Year1945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014

Request TypeNot SureAssessmentIntensive Outpatient Treatment

Other Information

*

• I understand this form is not for emergencies. If this is an emergency, I will call 911 or go to the nearest emergency room.

*

• I consent to be contacted by The Haven about scheduling and services.

Submit

This form is for scheduling and general questions only. If you or someone else is in immediate danger or experiencing a crisis, please call 911 or go to the closest emergency room right away.