Request of Information

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Application For Services

If you feel you're ready to take the first step towards recovery, download Footprints in Recovery Application Questionnaire. Once you've downloaded it and completed it, email it to us (here) and we'll get back to you as soon as possible. You can also fax it to us at 252-441-8248 for faster processing. Please do not hesitate to call us as this is the fastest way to have someone discuss entrance to our drug and alcohol rehab.

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Request More Information

If you would like more information from us, please fill out the form below and we'll be sure to respond as soon as possible.

Please remember to leave a valid phone number where you can be reached, a preferred time to call you, and an alternative number if possible so that we can assist you as promptly. We WANT to assist you or your loved one right away.

Name *

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Phone *

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Email *

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Specific Needs:

Client's Addiction:

Client's Gender:

Client's Age:

Why are you seeking help for this person at this time?

What is the best way (time and phone number) for us to contact you?

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