Questions? Contact us today 714.540.9070

Court Programs

Outpatient Substance Abuse Submission Form

2900 Bristol Street, Suite #E103
Costa Mesa, CA 92626

714.540.9070

We work with all PPO insurances and have cash pay options available. Please contact us now to verify your insurance benefits!

Client Name*

Your Email

Phone Number*

Date of Birth* (DOB)

Insurance Company

ID #

Group #

Provider Services #

Additional Notes

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