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Who needs treatment?(Required)

Myself

Someone else

Preferred Method of Contact(Required)

Text

Call

Contact information for person completing the form

My First Name(Required)

My Last Name(Required)

My Email(Required)

My Phone(Required)

Contact information for person in need of Detox/Stabilization:

Client First Name(Required)

Client Last Name(Required)

Client Email(Required)

Client Phone(Required)

Birthdate(Required)

MM slash DD slash YYYY

Last 4 Social Security Number(Required)

Full Address(Required)

Type of Addiction(Required)

Opiates

Cocaine/Crack

Marijuana

Benzodiazepines

Amphetamines

Alcohol

Other

Method of use(Required)

Oral

Intravenous

Intranasal

Inhalation

Year of First Use(Required)

Date of last use(Required)

MM slash DD slash YYYY

Upload a picture of the front and back of your insurance card or complete the form below.

Submission type(Required)

Upload pictures of insurance card

Enter Insurance / Medicaid / Medicare ID Number

Insurance Card - Front(Required)

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 5 MB.

Insurance Card - Back(Required)

Accepted file types: jpg, png, pdf, jpeg, Max. file size: 5 MB.

Medicare / Medicaid / Insurance ID Number

Willing to travel?(Required)

Ready to enter Detox immediately?(Required)

Description Information(Required)

By clicking "submit" and providing Monarch Detox Inc. with this information, I am giving my consent for this information to be used to verify my eligibility for the Monarch Detox Stabilization Program. I further certify that to the best of my knowledge, the information provided is true and accurate.

Monarch Detox Inc.

Bentonville, AR
Phone: 800-994-5091
Email: admissions@monarchdetox.com

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