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The information you submit on this form will be used internally for the purposes of processing and responding to your request. It may be routed internally in order to find the most appropriate member of staff to handle your request and your contact information will only be used to respond to your inquiry if you indicate permission to do so.

In addition, the information submitted may become a part of your permanent chart or treatment record at The Emily Program upon your utilization of The Emily Program services and this information may be used in the planning of treatment and care provided to you. At the time you utilize The Emily Program's services, The Emily Program's Notice of Privacy Practices, other HIPAA and information privacy and security policies will apply to the information submitted on this form and to any other information that The Emily Program maintains about you and the care provided to you.

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Recovery for life is possible 888-364-5977

Recovery for life is possible


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