CONTACT | Restoring Health

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RESTORING HEALTH

OUTPATIENT CLINIC

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CONTACT US

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First Name

Last Name

Phone Number

Email

Subject of Inquiry:

Who is this for?

What type of insurance provider do you currently have? *

American Indian Health Program

United Insurance

Arizona Complete Health

Mercy Care

Blue Cross Health Insurance

Have you had treatment before? *

No

Yes

If seeking admission, what is your timeframe?

Which outpatient location do you want to attend?

Are you currently working with a clinical professional? *

No

Yes

How did you hear about us?

Preferred method of contact (check all that apply): *

Phone

Email

Text

Additional Comments

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