Aviv Recovery

236 Clearfield Ave Suite 205 Virginia Beach, VA 23462

Are you seeking help for yourself or someone you care about? *

For myself

For my spouse/partner

For my child

For another family member

For my Friend or Colleague

Just exploring options

What type of addiction or behavior is causing concern right now? *

Alcohol

Opioids (heroin, fentanyl, pain pills)

Prescription medications

Cocaine / Meth / Stimulants

Marijuana

Gambling

Sex / Pornography

Other

(You may choose more than one)

Has treatment been attempted before? *

This would be the first time

Outpatient

Detox under medical supervision

Residential rehab - Inpatient

Multiple past attempts

How urgent does the situation feel right now? *

Immediate help needed (today/ASAP)

Within the next few days

Within the next week

Just gathering information

Not sure yet

What insurance provider do you have? (If known) *

(Example: Medicaid, Aetna, Cigna, Blue Cross Blue Shield)

What is your Zip code? (this helps us know that we are reaching people in our area) *

What is your Full Name? *

What is your best phone number? *

What is your best email address? *

I agree to the terms & conditions provided by Aviv Recovery, and by providing my phone number, I agree to receive text messages from Aviv Recovery.