Intake Assessment

Please fill out the form below and click submit to begin the process. We are only determining if Second Chances could be a good fit for you or your loved one’s current treatment needs. We are not here to judge your situation. We know that reaching out for help is a courageous step.

Once you have completed the online intake form and submitted it, we will review the information and contact you.

Please tick all that apply

Referer's Contact Information