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Admissions and Intake Form

Please fill out the following form to begin the admissions process or ask questions about Ridgeback Recovery.

First name

Last name

Phone

Email

State/Province & Country

Who are you seeking information for? *

Self

Family or friend

Client

Other

What role best describes you? *

Client

Family or friend

Therapist/mental health professional

Attorney

Treatment center

Other

What best describes the reason for your inquiry? *

Porn addiction

Sex and love addiction

Sex offending behaviors

Chem-sex addiction

Trauma healing

Other

Best way to reach you *

Phone

Email

Best time to reach you *

Morning

Afternoon

Evening

Anything else you'd like us to know?

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