Addiction Marketing Specialists Preferred Provider
To ensure the accuracy of your listings for your facility, please be as detailed as possible when filling out this questioner.
Name Of Facility
Levels of Care
Inpatient (Hospital) Detox
Residential Detox (DTX)
Residential Treatment (RTC)
Partial Hospitalization (PHP)
Intensive Outpatient (IOP)
Outpatient Treatment (OP)
Insurances Not Accepted
Limitations(What do you refer out?)
Any additional information you'd like us to convey before making a referral ?
Please provide the details on your referral process & acceptance lead time
With our clients permission may we email you demographic and insurance information?
Primary Contact First & Last Name
Primary Contact Phone
A copy of your responses will be emailed to the address you provided.