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Information Request

We are committed to your privacy and will not share your personal information with outside partners.

Click on the links below to download a PDF of our brochures now:

 
Please mail me information on the following topics:
     
  (Unity Behavioral Health is not identified on the envelope)

Chemical Dependency Programs for Teens
Chemical Dependency Programs for Adults
Chemical Dependency Programs for Older Adults
Family Programs, Support, and Interventions
Mental Health Programs
   
  * indicates required information.
  *First Name:
  *Last Name:
  *Address (line 1):
  Address (line 2):
  *City:
  *State:
  *Zip:
     
Please call me to schedule a confidential chemical dependency evaluation.
     
  * indicates required information.
  *Phone Number:
(We appear as “unknown” on Caller ID.)
  *Contact Name:
  *Best time to contact me:
    Morning (8:00-11:30 a.m.)
Lunch time (11:30 a.m. – 1:30 p.m.)
Afternoon (1:30 – 4:30 p.m.)
  *If you are not available when we call, please indicate if you would like us to leave a message:
    Yes, please leave a message
No, please do not leave a message
     
  View list of information I will need to schedule an evaluation