Patient Enrollment

Our associates are highly qualified and experienced, and are passionate about the care they provide. Not only will our providers treat your existing conditions, we will also help to create a custom recovery plan that's right for you. We strive to help you improve your quality of life.

Please begin by completing each page of the A101 Patient Intake Packet. Click submit when finished.

A Patient Representative will contact you to complete the enrollment process. 

​*All forms are made and processed through 123 Form Builder. Your information is secure, and will only be used for the purpose of building your patient file with Addiction Care 101. View 123 Form Builder’s Privacy Policy here.