Request A Counselor Callback: This Service is for Asheboro and Greensboro, NC Area Clients Only

calback-triage-page2Completing the form below will provide the ADS counselor with important information about your situation & treatment needs. The information that you provide is for ADS screening purposes only and will be kept confidential. An ADS counselor will contact you within two business days to discuss your treatment options. If you are experiencing an emergency, please call 911 immediately or go to your local hospital emergency room.

Medicaid or Insurance (if applicable)
(if applicable)
(if applicable)
(list insurance name, and your member #)
Drugs of Abuse - check substances below you have used
Briefly describe your substance abuse problem:
Prior Treatment Episodes for Substance Abuse
Facility Name, When, and Location
Have you ever been in a methadone program, or received a prescription for suboxone?
The number of self-help meetings attended in past 30 days:
Please list your medications and the reason they are taken.
Medications, Foods, Insect Bites
Please describe
Privacy Notice

Caution: This submission form is strictly for individuals seeking treatment services from ADS. Using this form to submit falsified data or impersonating the identity of another person is a Federal offense and punishable by law.

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