Destiny Recovery Center

1539 Carolyn Ct. Redlands, California 92374

Who are you seeking 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 right now? *

Alcohol

Substance Abuse

Mental Health

Has treatment been attempted before? *

This would be the first time

Outpatient

Detox under medical supervision

Residential rehab - Inpatient

Multiple past attempts

Currently in treatment

How urgent does the situation feel right now? *

Immediate help needed (today/ASAP)

Within the next few days

Within the next week

What insurance provider do you have? (If known) *

Anthem BCBS

Medi-cal / Medicaid / Medicare

UHC/UMR

Tri-West

Beacon/Carelon

Aetna

Cigna

Direct payment

Other

No insurance

Is your health insurance a PPO or HMO? *

PPO

HMO

Not sure

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

What is your Insurance member ID?

Full Name *

Date of birth *

Email *

Phone *

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

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