Intake Information

If you are 18 or older, we invite you to seek our help in getting on the path to recovery. If you are interested in our programs and services, please complete and submit the form below. You will be contacted by the next business day. Stella Maris’ trained and compassionate staff stands ready to provide the treatment, guidance and support you need to address your addiction.

Gender:
Health Insurance?
Type of Insurance:
Have you received treatment at Stella Maris Inc. in the past?
If yes, approximately when?
Please check treatment level you are seeking:
If "other" what treatment are you seeking?