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Corporate Office:
Villareal and Associates, Inc.
PO Box 3118
Beaumont, CA 92223
Phone: 888-373-0357
Email: josie@villareal.com
Fill Out The Form Below To Receive A Call From Our Qualified Addiction Specialists
Note: any and all information submitted is completely confidential.

Name (*)
Email (*)
Phone
Alternate Phone
State
Contacting For
If Others, Please Enter Their Name Here
Time Zone
Preferred Method of Contact
If You Prefer to Contacted by Phone, Please Provide The Best Time to Call:
What is/are The Primary Drug(s) of Abuse?
Alcohol Cocaine
Crack Heroin
Methamphetamine GHB
Ecstasy Inhalants
Ketamine Prescription Pain Killers (Morphine,
OxyContin, Vicodin, Fentanyl)
Prescription Benzodiazepines (Xanax, Klonopin, Valium, etc.) PCP
Marijuana Methadone
LSD Other Drug
Eating Disorder (Anorexia, Bulimia, Binge Eating, Overeating) Sexual Addiction
Gambling Addiction Other Addiction
Drug History
At What Age Did The User First Take Drugs?
How Old Is The User Now?
What Are The Resulting Problems of The User's Addiction?
What Is The Family's Attitude Toward The User's Addiction?
Does The User Admit to Having a Problem?
Does The User Want Help?
Is The User Willing to Leave His/Her Home Area to Get The Best Treatment Available?
Medical History
Has The User Been Diagnosed With Any Mental Health Problems?
If Yes, Please List The Conditions And Any Necessary Details
Has The User Been in Treatment Before?
If Yes, When and Where?
Does The User Have Medical Insurance?
If Yes, Please Select The Type of Insurance The User Has
If Necessary, How Much Out-of-Pocket Money is Available for Private Rehab?
Does The User Have Legal Issues?
If Yes, Please Describe
Please Provide Us With Any Additional Information or Questions You May Have Here:
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