Drug and Alcohol Rehab Application Form

If you or someone you love is experiencing an addiction to drugs or alcohol and are ready to get help, you can get started on your recovery right now by having your insurance verified. Simply fill out the form below to begin.

If you have any additional questions about treatment, or if you need assistance with the form above, please contact us directly at .

FAQ’s About Applying to Drug & Alcohol Rehab

How Do I Apply for Rehab?

The fastest, easiest way to apply for rehab is by filling out the form above. This provides our team with the information needed to help you begin the admissions process, bringing you or your loved one a step closer to recovery.

Do not hesitate to reach out to us. We are available 24 hours a day, 7 days a week at .

What Happens After I Submit the Rehab Application?

After you submit the rehab application above, you can expect to receive a call from one of our kind, compassionate admissions navigators. They will invite you to share your story, help you understand the treatment process, and begin helping you create a personalized treatment plan that meets you or your loved ones needs. Please keep in mind that filling out a rehab application form does not mean you are obligated to obtain services with AAC.

Is the Rehab Form Confidential?

Yes. All information you provide AAC (including the form above) is confidential and legally protected under HIPAA. You can rest assured that when working with our team – both over the phone and in person – your personal details are secure and only accessible to you.