Please fill the Form below :

Your Name (required) :

Your Phone (required) :

Your Email (required) :

Best Time To Call You :

City/Town :

Province :

Addicts Name :

Your Relationship to Addict :

His/Her Drug(s) of Choice :

Is the addict currently on or have they ever been on any prescribed medication of a mood altering or Narcotic nature?

Has the addict ever received treatment for their addiction?

If yes, what kind of treatment? Did they complete the treatment?

Has the addict ever received any treatment by a Psychiatrist, Psychologist or been Diagnosed with a mental illness?

Other specific health requirements which could affect recovery or treatment :

Additional Information :

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Contact Information

Thank you for your interest in our free drug and alcohol rehab referral program in Canada. Please fill out this information form completely so that we may better address your individual rehab needs.
All information collected is held in the strictest confidence.
Canadian Drug Rehab will assist you in locating a qualified and professional drug or alcohol rehabilitation facility to achieve complete rehabilitation. One of our Rehab Placement Specialists will call you back at your convenience.

Phone: 1-888-391-9295