Rotary Recovery LLC

3100 Dundee Rd. Suite 502 Northbrook IL 60062

Who are you looking to receive 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? *

Mental Health

Alcohol

Benzodiazepine

Opioids

Stimulants

Other substances

Marijuana

Inhalants

Other

Have you previously received treatment for this? *

This would be the first time

Multiple past attempts

Currently in treatment

How urgent is your need for treatment right now? *

Immediate help needed (today/ASAP)

Within the next few days

Within the next week

What insurance provider do you currently have? *

Medicaid

Medicare

Tri-care

Commercial

Self-pay

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

Is there a more convenient date and time for us to call you? *

Date & Time

Full Name *

Date of birth *

Phone *

Email *

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