Apply for assistance.

If you or someone you know is in need of treatment, please fill out the application here and one of our intake specialists will be in touch shortly.

Name

First Name

Last Name

Phone

(###)

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What state are you in?

Are you requesting assistance for yourself or a loved one?

Have you (or loved one) ever sought treatment before?

How did you hear about "ORA"?

Please type a brief description on how we can help.