Contact Person Name * First Name Last Name Contact Person Email * Contact Person Phone Number (###) ### #### Client Name * First Name Last Name Client Date of Birth * This group has a required age range. MM DD YYYY What services are you interested in? Alliance Adolescent Substance Group Other Who is your insurance carrier? How did you hear about us? Alliance Clinician Previous Alliance Services Local Community Referral Therapist Referred Word of Mouth/Friends/Community Google/Internet Search Facebook Other Social Media Other Message * Please include information about the client's experience or association with substance use. Thank you for your submission!You should be receiving a response email from one of our Alliance therapy group moderators soon. Alliance Adolescent Substance Use Therapy Group Application
