If you feel this is an emergency,  please call 911 

                           CCLogofin (2)   From the moment you arrive at our AA&E Retreats                                                      you will be treated as our guest with respect, care and the dignity you deserve.           

Please ask your questions or state any special needs, and we will respond promptly. 
All information is held in a secure format
absolutely confidential.

* Required fields

Name of Client: (First, Middle, Last)*

Contact (if you are completing this form for someone else, please enter your name):

Email:*

Phone:*

Sex:*
Male Female

Describe Any Special Needs You May Have:*
Detox Needed? Yes ____ No_____    Would an Intervention be helpful?     Extended-Care,  Sober-living
DETAILS

Is the individual in treatment, or had treatment in the past. If yes, please tell us a little about the experiene below:
Please give us an idea of when the patient may want to come into treatment? 

Please explain; current physical & emotional conditions: Stress/Panic Attacks, Obsessive Compulsive Behavior; Anger-Pain *

Is the individual taking any prescription medication:
If yes please specify dosage and frequency:

Why do you think there is a problem?: When and why do you think the problem began?   Patient's occupation is-


 Click for more information      *  What will my insurance pay? 


                          Thank you for your help, upon receipt and review we will respond to you promptly. 
 

                                                          The Brain Health & Recovery

CCLogofin (2)Copyright © 2000, AAERetreat / The Crosby Recovery Centers. All rights reserved.
AA&E Retreat/ Crosby Centers are recognized around the world providing affordable effective individualized programs.
The success of our programs have given patients their best opportunity to reclaim their life and achieve sustained recovery.
We are a private-pay facility. Forensic Doctors And Specialists  Professionals Fully Licensed by the State of California.
THE COMPREHENSIVE WHOLE PERSON 'holistic' TREATMENT