Make an Appointment

Make an Appointment

Please complete the form below, and we will contact you shortly.

    PRE-SCREENING FORM

    Name

    Phone#

    Today’s Date

    Date of Birth

    Tell us why you need help?

    Preferred Method of Payment:
    Private Pay via cash, check or card
    Insurance
    I’m not sure, I just need help

    If Insurance, please list provider and contact information for authorization of services:

    Number of People in Household and Household Annual Income Level (must bring proof to admission appointment):

    Have you ever been treated for substance abuse or psychiatric problems in the past? If so, where and when?

    Please describe your current emotional state:

    Please list your Substance Use History:

    Drug TypeAge of First UseAge of Regular UseHow much and how often?

    When was the date and time of your last drink or drug use?

    Would you like a referral to a detoxification center before you begin treatment?

    When is the best time to contact you?

    Your Email (required)

    Someone from Restored Life Services will contact you within 24 hours.

    “Restored Life Services of Arkansas is in compliance with Titles VI and VII of the Civil Rights Act and is operated, managed and delivers services without regard to age, religion, handicap, sex, race, color, or national origin.”